an editorial…

Posted on Wednesday 23 May 2012

Re-reading my last post, I think I got entangled in the facts, the front page story, and didn’t fully make it to the editorial page. Here’s the editorial…

From it’s earliest days, our DSM-5 Task Force set out to make a change. They were going to realize the dream of the St. Louis fathers of the original DSM-III revision – to move the psychiatric nosology from it’s 30 years of mere description to the longed for biological base that would put us on an equal footing with the rest of medicine. Hard science in psychiatry was booming when they started, and they felt the time was right. They set up a series of conferences – gatherings of experts to lay the base for the coming paradigm shift. And while they were meeting, something happened [a soft version of Rome is burning], but more importantly, something didn’t happen.

The thing that happened was the exposure of widespread scientific corruption in the psychiatric literature and academic medicine, fueled by an alliance with the pharmaceutical industry. The thing that didn’t happen was that the scientific basis for the proposed change didn’t materialize. And further, they had taken the accomplishments of their predecessors, Drs. Robert Spitzer [DSM-III, DSM-IIIR] and Allen Frances [DSM-IV], for granted. They failed to realize that these former successes were built on a base of hard work, organization, and attention to details. The descriptive DSMs are soft systems. Soft systems require a lot of careful shepherding. Systems based on hard science are a walk in the park by comparison – hard data carries the day. They had counted on the coming of the future science for their new system, been lax with the groundwork and preparation required to improve the one we had, and the clock ticked on.

Then they made a big mistake. When the DSM veterans [Spitzer and Frances] began to speak out, DSM-5 Task Force leaders saw them as nosy parkers holding on to the past rather than as wise elders with important counsel. They were aided and abetted by a worst case adviser, Dr. Alan Schatzberg, then president of the APA [and under US Senate scrutiny]. So they pressed ahead. They had banked on future science and lost that round. They made a second wager – that the single pass Field Trials would exonerate them. Well, that was as bad a bet as the first – the Field Trials bombed. They were so bad that they created a bigger problem than before. Earlier, it was their dream of a premature or misdirected paradigm shift that was being wagered, but with those dismal Field Trial results, they will be putting the fate of the whole DSM system and the DSM-5 Manual on the gaming table.

The question now seems to be whether the APA will make a third bet, that the success of the DSM Manuals in the past and the former prestige of the APA will carry them forward to publication on their current schedule. From any angle I can see, the stakes are too high, the bet way too risky. Relying on claims of expertise as APA president-elect Dr. Jeffrey Lieberman does in his piece on Fox News yesterday [Counter-argument: Changes to DSM-V bring needed improvements] seems folly right now.
    For this revision, the APA recruited more than 160 of the top researchers and clinicians from around the world to be members of the DSM-V Task Force, Work Groups and Study Groups. These experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, and public health were rigorously vetted for any conflict of interest using guidelines derived from other academic professional organizations and from the federal government itself and have worked assiduously for over five years to scour the scientific literature and determine whether any changes to existing DSM-4 diagnoses and additions were warranted.  They participated on a strictly voluntary basis and come from several medical and health care disciplines including psychiatry, psychology, pediatrics, nursing and social work…
There may be times when claims of expertise might be effective, but this doesn’t seem like one of those times. This is a time for demonstrated expertise, and that’s a missing commodity in this story. This is the time for the Trustees of the American Psychiatric Association to just say "No" and take back the helm, since the other people involved don’t seem to know how to act responsibly right now.

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