It is an unsubstantiated claim that the proposed changes to substance abuse and dependence disorders in the new Diagnostic and Statistical Manual of Mental Disorders will lead to millions of people being labeled “addicts.” In fact, the D.S.M.-5 Work Group’s analyses of data from 200,000 people indicate that the minor changes proposed to D.S.M.-5 criteria will not increase the prevalence of substance use disorders. Further input and evaluation from our various review groups, field trials and public comment from our Web site will be assessed before final recommendations are presented to the American Psychiatric Association’s board of trustees.
These proposed changes combine the D.S.M.-IV categories of substance abuse and substance dependence into D.S.M.-5’s substance use disorder. In this one overarching disorder, the criteria have not only been combined but also strengthened. Previous substance abuse criteria required only one symptom, while the D.S.M.-5’s revised mild substance use disorder [not addiction] requires two to three symptoms. This evidence-based change raises the requirements from D.S.M.-IV rather than broadening them. Like the National Institutes of Health, whose research supports the proposed changes, we are confident that the proposed criteria will lead to improved diagnosis for people seeking help for substance use disorders.
I hate to be so generic in my reactions to the responses of the DSM-5 Task Force, but this one got to me. From the original article:
The broader language involving addiction, which was debated this week at the association’s annual conference, is intended to promote more accurate diagnoses, earlier intervention and better outcomes, the association said. “The biggest problem in all of psychiatry is untreated illness, and that has huge social costs,” said Dr. James H. Scully Jr., chief executive of the group.
Under the new criteria, people who often drink more than intended and crave alcohol may be considered mild addicts. Under the old criteria, more serious symptoms, like repeatedly missing work or school, being arrested or driving under the influence, were required before a person could receive a diagnosis as an alcohol abuser.
“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”
It’s hard to see how detecting untreated illness, ‘mild’ addicts, setting the bar lower, or treating people earlier wouldn’t increase the prevalence. His comment doesn’t really make any sense. In the article itself, Dr. Scully made an equally awkward comment:
Some critics of the new manual have said that it has been tainted by researchers’ ties to pharmaceutical companies. “The ties between the D.S.M. panel members and the pharmaceutical industry are so extensive that there is the real risk of corrupting the public health mission of the manual,” said Dr. Lisa Cosgrove, a fellow at the Edmond J. Safra Center for Ethics at Harvard, who published a study in March that said two-thirds of the manual’s advisory task force members reported ties to the pharmaceutical industry or other financial conflicts of interest.
Dr. Scully, the association’s chief, said the group had required researchers involved with writing the manual to disclose more about financial conflicts of interest than was previously required. Dr. O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction. He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction. “I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.
This also contains a response from Dr. O’brien that is of note, "…adding that he had never made any money from the sale of drugs that treat craving." Any perceptive reader would have noticed the earlier sentence "…has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving" and would insert the word "yet" ["… never made any money from the sale of drugs that treat craving yet"]. These are the kind of response that were called "non-denial denials" in the days of Karl Rove and other politicians [eg Clinton’s "I didn’t inhale"].
I’m not proposing that they learn to respond to criticism better. I think what I’m commenting on is that they don’t actually respond to the content of the criticism. They just say "no," indicating that they haven’t really engaged the issue. That’s the thing that makes their responses so unpalatable. But worse, denying the impact of conflicts of interest in 2012 is going to fall on dead ears. Denying that the new criteria will foster increased prevalence is equally flat. They sound dumb. Experts gain nothing by sounding dumb. Particularly when their changes are only backed up by "expertise."
I’ve been poring over Dr. Spitzer’s early papers, and while I’ll argue with some of his conclusions, he was trying hard to put the DSM on a solid scientific footing. The changes discussed here are public health arguments based on speculative future gains. That’s not how you define a medical condition. Even if they were well meaning, they’re opinions, not science. They might be right and they might not. Dr. Spitzer’s science might be questioned and/or defended, but it’s at least there as an object of discussion. The DSM-5 Task Force has wandered afar from that essential vision of their predecessors – and they don’t seem to know it…
The biggest problem in all of psychiatry is untreated illness.
So psychiatrists see a lot of patients they can’t hang a label on? I find that hard to believe. Perhaps there will be a public campaign made by non-profit organizations to spread the word about the dangers of untreated “cravings”.
I used to be so grateful to psychiatry.