1 Boring Old Man

Why is DSM being revised?
^{DSM has been periodically reviewed and significantly revised since the publication of DSM-I in 1952. Particularly over the past two decades, there has been a wealth of new information in neurology, genetics and the behavioral sciences that dramatically expands our understanding of mental illness. Researchers have generated a wealth of knowledge about the prevalence of mental disorders, how the brain functions, the physiology of the brain and the lifelong influences of genes and environment on a person’s health and behavior. Moreover, the introduction of scientific technologies, ranging from brain imaging techniques to sophisticated new methods for mathematically analyzing research data, have given us new tools to better understand these illnesses.}

I haven’t experienced the past two decades in psychiatry in quite the same way. As I’ve seen it, this period has been an age of corruption unequaled in the history of medicine. The main body of research has been interminable drug trials, a patchwork grid of the all available drugs tested against all available diseases. The ancillary new industry of Clinical Research Organizations [CROs], Clinical Research Centers [CRCs], and Clinical Rating Scales [HAM-D, QIDS, PANS, MADRS, SANS, BPRS, CGI, etc.]  has produced an infinite array of monotonous graphs in monotonous journal articles about pharmaceutical industry financed studies, often written by professional writers with guest author psychiatrists who may or may not have been involved in the process. It has been an a time when psychopharmacologic agents have been introduced one after another following a predictable life cycle. First, there’s a exuberant marketing phase supported by an army of psychiatrists which accentuates the positive and eliminates the negative. Then comes a period when the unreported adverse effects start to come to light and are denied, while the army of psychiatrists deploys to hawk the medications across the land. By the time the adverse effects are finally undeniable, warnings are issued but the earlier momentum carries the drug to the end of its patent life. And, by the way, beside the adverse effects, it usually turns out that the drugs weren’t so effective after all. Then come the legal suits for damages and false advertising and the drug companies end up parting with some small fraction of their profit – ready for another go-around. That’s the front page of the last several decades that I’ve known in psychiatry.

Meanwhile, the love affair with brain biology has been sustained by a literature of future-think, review articles and opinion pieces about what’s coming soon – just around the corner. I have little doubt that somewhere down the line, neuroimaging will actually show us some interesting things about brain circuitry that might even lead us to an understanding of something that has to do with clinical mental illness. But it hasn’t really happened yet. I remember in around 1985 being told by our new chairman that neuroimaging was about to revolutionize our understanding of mental illness. So by my reckoning, neuroimaging is entering its second quarter century being the coming revolution in psychiatry. Nor do I doubt that we’ll learn something from genomics, but it’s not here yet. And "the lifelong influences of genes and environment on a person’s health and behavior" is no great conceptual leap.

Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
^{by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.}
American Journal of Psychiatry 168:672-674, 2011.

^{In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…}

^{The seminal article by Robins and Guze on diagnostic validity, which proposed a classification of psychiatric illnesses based not on psychodynamic, a priori hypotheses but rather on external, empirical indicators, built a direct pathway to DSM-III. Their proposed classification steps included identifying core clinical features, conducting differential diagnosis to separate the condition from similar disorders, gathering laboratory data, assessing temporal stability of the diagnosis, and determining familial aggregation of the disorder. The resultant explicit criteria featured in DSM-III and subsequent editions have significantly improved our understanding of psychiatric disorders, but they did not come without a price. While diagnostic reliability has thrived, large-scale epidemiological studies have underscored the inefficiency of DSM’s criteria in accurately differentiating diagnostic syndromes, especially in community samples. With reification of the criteria through revised editions of DSM-III-R and DSM-IV, proliferation of diagnostic comorbidities and overreliance on the "not otherwise specified" category have continued…}

Psychiatric Diagnosis in the Lab: How Far Off Are We?
Medscape News
by Jeffrey A. Lieberman, MD
09/28/2011

^{…we anticipated that this iteration of the DSM would incorporate biological markers and laboratory-based test results to augment the historical and phenomenologic criteria that traditionally are used to establish psychiatric diagnoses. Sadly, this has proved to be beyond the reach of the current level of evidence…}

^{In recent years, however, we have seen the emergence and refinement of a number of different technologies that I predict will, within our professional lifetimes and hopefully within the next 5 years, lead to the incorporation of laboratory-based tests for psychiatric diagnosis. When these will be proved to a satisfactory level of evidence and when they will be reimbursable by third-party payers, we can’t know specifically, but I predict this will happen fairly soon. We are seeing the evidence of that even now. The tests that appear to be emerging as the first to be marketed are ones that are based on the proteomic or metabolomic or biochemical analyses of plasma or cerebrospinal fluid. A series of different types of microarray panels have been developed that examine the profile of a series of analytes in plasma, serum, or cerebrospinal fluid…}

^{A second modality that is likely to be implemented for psychiatric diagnosis is that of imaging techniques; here we’re talking about both nuclear medicine imaging with PET and MR imaging with either structural, spectroscopic, or functional imaging applications… They yield clear differences between, diagnostic groups such as schizophrenia or depression on one hand and healthy volunteer controls or nonaffected individuals on the other. The problem is that the distributions of the values of the control vs patient groups still have too much overlap and are not sufficiently differentiated as to provide high enough positive predictive value at the individual patient or subject level. But I predict that it won’t be too long before these are refined, the results will become more robust, and these will contribute to a profile or augment the information that clinicians have to establish their diagnosis.}

^{Finally, genetic testing will also come into play. As you probably know, commercial companies already are marketing DNA testing. They provide a "readout" of your genotypes for all of the known coded human genes along with associations with specific diseases in the different organ systems that these correspond to, to the best level of evidence that currently exists. …there is no reason psychiatry cannot begin to use these as other fields of medicine have done. Because all mental disorders will almost certainly prove to be polygenic or multigenic, we will need a gene profile to utilize in terms of diagnostic information…}

Brain circuitry model for mental illness will transform management, NIH mental health director says
British Medical Journal
by Caroline White
1 September 2011

^{[A] seismic shift had been driven by what he described as three “revolutionary changes” in thinking, the first of which was that mental illness was increasingly being recognised as a disorder of brain circuitry, rather than as a chemical imbalance, thanks to neuroimaging techniques and the discovery of some key biomarkers. Secondly, mental ill health was now recognised as a developmental disorder for which early intervention was vital, said Professor Insel, highlighting US research showing that 50% of study participants had reported the onset of mental health problems by the age of 14, and 75% by the age of 24. “We are still stuck with getting to the problem very late. The future will be about understanding the trajectory of illness so that we can identify the first signs before it develops into psychosis,” he said… Pre-emptive strategies, based on the brain’s plasticity, could include the development of a credible risk score coupled with some, or all of, cognitive training, psychosocial approaches, education, and the use of specially designed video and computer games—a technique that was already being tried out in Australia, he said. But we need to recognise the limits of what we have, he cautioned. “We are not yet at the point of identifying those at high risk as early as we would like.”}

^{The third change was the recognition that mental ill health is a complex mix of genetic and experiential factors. “This is not new,” he affirmed. “But what is new is the ability to probe the genetics of the disorder.” But whether the drug industry will take up the challenge, in the absence of plentiful molecular targets, is unclear, he suggested. “[It] has invested in me too compounds—and sometimes in compounds that are identical to someone else’s. And let’s be frank, that has worked really well for them,” he said. But he declared, “Antipsychotics and antidepressants are not very good.” Much more research into the biology of mental illness was needed, he said. The consequences of the “remarkable lack of progress” in tackling mental illness effectively were legion, he said. Depression alone was the number one source of disability, he said. “The rate of suicide is way way beyond the rate of homicide in most of the world. In the US, it’s double the rate of homicides and higher than road traffic accidents,” he commented, adding that suicide killed more soldiers in the US military than enemy combat…}

Neither of these two views of psychiatry are particularly savory. One portrays academic psychiatrists in collusion with a ruthless and greedy pharmaceutical industry and practicing psychiatrists in the back seat of mental health care writing prescriptions. The other has the neuroscientist among us cheerleading with speculations but privately desperate for something to validate their efforts [and coming up short]. I suppose the good news is that I know a lot of psychiatrists and none of the ones I know personally fit into these cartoon slots I’ve been describing. All of us have been affected by the changes in psychiatry over the last three decades, particularly the changes introduced by managed care and third party payers – some more than others. These days, there’s a tremendous pressure to prescribe medications, not just from the changes in practice but from the patients themselves. And I can assure you that there’s no call coming from rank and file psychiatrists for a revision of the Diagnostic and Statistical Manual. I’ve been back in Atlanta more than usual lately, seen lots of friends, taught younger psychiatrists some, and no person has even mentioned the DSM-5 revision. In fact, there seems to me to be a torpor on the land – not much connection between practicing psychiatrists and the "ruling class" that publishes the articles I write about here or that seems so excited about the DSM-5. The framers of the DSM-5, the KOLs like Dr. Lieberman who speak about the dramatic breakthroughs in neuroscience just around the corner, and our NIMH Director Tom Insel who seems to never tire of quoting his "burden of mental illness" statistics and making pleas for more biological research all share something in common – a highly inflated view of their relevance to clinical psychiatry in 2011.

So Why should Psychiatrists sign the petition to reform the DSM-5? The answer is easy. There’s absolutely no need for the revisions being proposed. What does Psychosis Risk Syndrome add? "Maybe" diagnoses have no place in any diagnostic scheme. The proposed gyrations of the Personality Disorders revisions are too confusing to follow and offer nothing useful to a clinician so they’re unlikely to be followed. Removing the bereavement exclusion from MDD is beyond silly. Nobody’s going to follow that. And it expands a diagnosis that is only useful for antidepressant drug makers anyway. MDD should instead be deconstructed into the multiple clinical syndromes lumped inappropriately in 1980. None of the other new categories adds anything that’s relevant to clinical practice. So Psychiatrists should sign the petition as a way of stopping the silliness and saying "Who are you people?" and "Who do you think you’re helping with this? It’s not us or our patients." And maybe something like "All you’re doing is adding more embarrassment, and we’ve had more than our share of that."

Sign here…