all over the place…

Posted on Sunday 31 March 2013

Diagnosis and its Discontents: The DSM Debate Continues
Psychiatric Times
By Ronald W. Pies, MD
March 29, 2013

“As to diseases, make a habit of two things—to help, or at least to do no harm.”
“An agnostic is someone who doesn’t know, and di- is a Greek prefix meaning “two.” So “diagnostic” means someone who doesn’t know twice as much as an agnostic doesn’t know.”
–Walt Kelly, Pogo…

A funny thing happened to me on the way to the New York Times “Sunday Dialogue”—I made myself unclear. This is not supposed to happen to careful writers, or to those of us who flatter ourselves with that honorific. So what went wrong?

In brief, I greatly underestimated the public’s strong identification of psychiatric diagnosis with the categorical approach of the recent DSMs. But whereas my letter to the Times was indeed occasioned by DSM-5’s release in May, my argument in defense of psychiatric diagnosis was not a testimonial in favor of any one type of diagnostic scheme—categorical, dimensional, prototypical or otherwise.
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I bear Dr. Pies no ill will. He’s a retired psychiatrist like me. His intro-bio reads:
Interesting topics. I expect if I knew him, we could find plenty to talk about. My impression reading his blogs from time to time is that he’s had a long career and been seen as something of an expert, well earned. He writes like a chronic expert – opinionated but with humility and tact. In a lesser venue, I’ve been an expert at times in my life – a status that I personally didn’t like very much – too vulnerable for my temperament. But if I had to guess, Dr. Pies was much more comfortable than I was in that clothing. This time, he obviously realized that he stepped into some deep doo-doo with his NYT Letter to the Editor last Sunday [Sunday Dialogue: Defining Mental Illness][looking in the mirror…] and this is his reaction to the reaction as he attempts to graciously exit deep doo-doo status, stage left. I give him credit for knowing when he’d set out to explain something but met an audience who was in no mood for explanations from psychiatric experts. I’m afraid that he’s been behind the firewall of the Psychiatric Times a bit too long and lost touch with the climate changes in the real world.

Being a chronic expert is a liability, since there’s no tenure for experts. Such people get used to people accepting their expert status and hanging on their words. But that can end in a heartbeat [see all there is to say…]. Jane Goodall’s expertise with Chimps didn’t translate so well to plants and it appears that she relied too heavily on her editorial assistant/ghost-writer/co-author person [speaking of deep doo-doo]. Dr. Pies didn’t make that kind of mistake. He assumed that all the criticism of psychiatric diagnosis was spillover from the DSM-5 Wars. He even got kind of Freudian and suggested it was displaced hostility towards mental illness. But he had that part ass-backwards. The hostility towards psychiatrists about diagnostic labeling is actually in sympathy to the mentally ill who can be actually harmed by being diagnosed – in all kinds of ways. Saying a person has a DSM diagnosis isn’t like coding appendicitis – it may make a person uninsurable or unemployable for life. That’s a big hurt. And there are other subtle consequences. These days, there’s a big suspicion that diagnostic inflation is partially motivated by people drumming up business. With the DSM-5 diagnostic inflation, that’s hard to refute.

In this  reaction to the reaction Dr. Pies makes what I consider a weak point – that doctors need to make diagnoses. Of course they do, but not in the Managed Care/DSM-5 way it’s done these days. I didn’t deal with insurance companies as a practitioner and was on no panels. When patients wanted to file insurance themselves, I producing bills with the diagnosis [ICD-9-CM] and session [CPT] codes. And I often saw it important to discuss this topic with the naive, as informed consent [do no harm has lots of meanings]. Diagnosis is something one does for a patient, not to or with a patient. Our diagnoses are more in the range of opinion than anyone would like to admit, at least the ones used for outpatients.

In that second paragraph I quoted above ["In brief, I greatly underestimated the…"], he is absolutely correct about his underestimating. Then he wanders off into semantics. I would have preferred that he stayed on point and explored why he was so far off. He, and psychiatry in general, are playing dumb here and this is no time for dumb. The DSM-5 is 6 weeks away, and it would be helpful if people like Dr. Pies who are influential but living in a cloistered world would begin to stop playing expert and get on board with reality. We’ve had years of playing to the wrong audiences – each other, pharma, managed care, tainted KOLs, etc. It’s time to listen to the critics to hear what’s right about what they’re saying. Not to find ways to discount them if they get carried away. Frustrated people do that, myself included.

As I say, I have no beef with Dr. Pies. Anyone who quotes Walt Kelly can’t be all that bad. But this is a time to suspend previous expertise, no matter how well earned, and take stock of the state of play. It’s impossible not to see that twenty-first century psychiatry has veered from the true path – badly. Admittedly, we’ve had a lot of help with that – the intrusions of third party carriers and pharmaceutical marketing departments. But our experts haven’t helped us very much either. A lot of them went over to the dark side and are stuck over there. We could use some help from people like Dr. Pies to help get things back on track. We’re in a time when "if you’re not part of the solution, you’re part of the problem" is really the right way to be thinking…

His response is not that bad as it stands, but he leaves out what almost all such responses leave out – diagnostic inflation, scientific corruption, collusion with industry, deterioration of our journals, overmedication, conflicts of interest, ghost-writing, etc. – the kind of trash that Kelly’s Pogo is looking at in that old Earth Day poster above. It’s all over the place…
    berit bj
    March 31, 2013 | 10:46 AM

    A more enlightened and honest view on the stigma of diagnoses can be found in the article “Renaming schizophrenia: a Japanese perspective, Mitsumoto Sato, World Psychiatry 2006, February 5

    Reading dr Pies’ article touched old wounds, as I was reminded of what I would have believed in the early years of my son’s descent into psychiatry, labelled with schizophrenia after 8-10 days in a place of many horrors, an acute ward, closed, locked in every meaning of the words.I’ve long since stopped reading the untrustworhy, misleading ,hypocritic Psychiatric News.

    March 31, 2013 | 11:09 AM

    when an acceptable “diagnostic payment code” is made the physician will get paid and the patient will gets car (service?)

    i am increasingly curious as to how the physician (practice/hospital) and patient experience of the “monetary link” between health problem, diagnosis, care and diagnostic code in other spheres of compares with that of physician (practice/hospital) and patients in mental health care (behavioral health?)

    March 31, 2013 | 11:25 AM

    1 Boring Old Man » all over the place…

    March 31, 2013 | 12:52 PM

    I’ve been reading Dr. Pies on and off for years. From what I’ve seen he always makes straw persons of those who disagree with him (or, if you want to look at it another way, projects some fantasy enemy); always condescends behind a faux-humble facade; always resorts to semantics; and always is an apologist for the psychiatry status quo.

    And from that, he’s made a reputation, which goes to show the place of logic and common sense in psychiatry.

    March 31, 2013 | 3:46 PM

    Oh, and just so you know how inappropriate Dr pies can be, he once sent me a letter and his book on “being the mensch” after he tracked me down from an alias I used as a political site on healthy care where he first posted an attack on Libertarian politics.

    Really is quite unnerving for someone to contact you without invitation. He never did acknowledge I paid him for his unsolicited book, nor did he ever apologize when I noted this transgression in other site’s policies in allowing anonymity in commenting.

    Not behavior of a mensch, eh?

    March 31, 2013 | 4:11 PM

    How is the insurance industry benefiting from this? People prescribing psyche meds have a tendency to push drugs that are still under patent, and to push them for life. Given that most people don’t need these drugs for life, if at all, how does it benefit the insurance companies to insist on codes that cost them more money, unnecessarily?

    Since insurance companies also benefit from more working people paying into the pool, how is that they are not looking at this?

    Anyway, psychiatry has the power to relegate people to lumpen-proletariat status at the drop of a hat. If they want to teach people that that’s what they get for asking for help, psychiatry is doing a bang up job of it.

    March 31, 2013 | 7:09 PM

    For an example of what I believe Altostrata is referring to (and some unintentional comedy), take a look at the comments section of this post from the Carlat Psychiatry Blog from a few years ago, specifically, the 2nd comment from someone poking a bit of fun at Dr. Pies, and the 5th comment, which is Dr. Pies’s response.

    April 1, 2013 | 2:20 AM

    To reprise an earlier comment:

    What I find most confusing in Dr. Ronald Pies comments comes in this paragraph:
    “Contrary to a popular misconception, there are indeed substantial differences between “ordinary” or “normal” grief associated with loss, and MDD. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The normally grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.”

    So, even if we take what Dr. Pies describes about grief at face value we would have an individual who could experience anguish and pain in “waves.” Presumably this could occur for most of the day for at least 2 weeks during the period after a loss. They can remain hopeful. Which of the DSM Major Depressive Disorder criteria are clearly precluded by the presence of hopefulness? They have the ability to be consoled. Which of the DSM Major Depressive Disorder criteria are clearly precluded by the presence of being able to be consoled. If the ability to be consoled is supposed to be a consequential distinction then is there any implication in the DSM that Major Depressive Disorder is not supposed to be diagnosed if the individual is capable of experiencing consolation from family members?

    It almost seems like he is saying that there are ways one can distinguish depression and grief, but the diagnostic manual has not seen fit to include them.

    1BOM, what am I substantively missing?

    Because that argument, in the context of a defense of DSM criteria, would seem to be absurd if that is a correct understanding.

    April 1, 2013 | 8:20 AM

    “”Saying a person has a DSM diagnosis isn’t like coding appendicitis – it may make a person uninsurable or unemployable for life. That’s a big hurt. And there are other subtle consequences. “”

    For many who were on psych meds and got off of them due to horrific side effects, the consequences have been worse than subtle greatly impacting our lives. But sadly, many in psychiatry refuse to believe this and find it easier to demonize us with the antipsychiatry label as Pies has a record of consistently doing.

    April 1, 2013 | 8:22 AM

    Sorry, I meant to say the consequences have been worse than subtle such as suffering from insomnia and other physical and neurological withdrawal issues.

    April 1, 2013 | 8:41 PM

    Health industry group: Replace psychiatrists with vending machines
    Measure to reduce health care costs

    1 April 2013 Health Insurance Times (Dubuque, Iowa)
    A health care industry thinktank, US Health Insurance Consortium on Cost, advocates replacing psychiatrists and other doctors with vending machines to prescribe and dispense antidepressants.

    “We believe this will cut the cost of psychiatric services significantly,” Uli Arnowsky, spokesperson for USHICost, said. “Our studies show the diagnosis and prescription process can be automated, with no loss in quality of care. Specialist costs are just not necessary for this type of treatment, and psychiatrists are overworked anyway.”

    USHICost’s plan is to make the Psychiatric Diagnostic Screening Questionnaire (PDSQ), based on the new diagnostic manual DSM-5, available online to health plan members. Answers would be captured in a database and analyzed to produce a recommendation for a prescription. A psychiatric nurse reviews the recommendations and authorizes the prescription, which is then attached to the patient’s database record.

    Vending machines, in convenient medical center locations and on a secure network, would be stocked with the most common generic antidepressants.

    “We prefer the generics,” Arnowsky said. “They’re part of the cost-cutting. Our studies show they’re just as effective as the name-brand drugs.”

    According to Arnowsky, to get a prescription filled, a patient would input a health plan ID and a password at a vending machine. The machine would look in the database, dispense the authorized prescription, and charge the copay to a credit card on file in the patient’s health plan record.

    “We really like the way this system keeps electronic medical records, too,” Aronowsky said. “It’s a win-win-win for all concerned.”

    Patients reporting side effects would be advised to see their doctors, who could then adjust the prescription if needed.

    “There’s a lot of trial and error in prescribing antidepressants already,” he said. “This system is no more error-prone than present prescribing practices. In fact, we put fuzzy logic in the system to rotate prescriptions among the antidepressants, because we’ve found doctors prescribe them in an almost random fashion. We built the human element right into the system — it thinks just like a doctor about these drugs.”

    He stated that USHICost’s studies had shown diagnosis by PDSQ was at least as accurate as by doctors, including psychiatrists. “This will take a big burden off primary care physicians, too, who are bearing the brunt of prescribing antidepressants,” he noted.

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