1 Boring Old Man

APA Attempts to Defend Itself
Psychiatric Times
By Allen Frances, MD
December 5, 2011

^{This blog is a follow-up to an earlier post. The great news is that there is an active public debate on DSM-5. The leadership of the American Counseling Association [ACA] recently sent a thoughtful letter to the leadership of the American Psychiatric Association [APA] that summarizes the most serious flaws in the DSM 5 and recommends the steps necessary to regain its lost credibility and earn the support of potential users. The letter has tremendous force because the ACA represents fully 20% of all the mental health professionals who will eventually have to decide whether to use DSM-5.}

^{The APA’s response to ACA is long-winded, something of a classic. The cloudy confusion in the APA response deserves more detailed deconstruction in later blogs — but for now, let’s maintain a tight focus on what is missing — 5 straight answers to these 5 simple questions:}

1. Why is APA not willing to have an independent external scientific review of questionable DSM-5 proposals – especially since its own internal, super-secret review process has been so badly discredited? APA response: There have already been multiple layers of review from its DSM-5 workgroups, task force, advisors, and scientific review group. The claim is that this constitutes an "independent" review, simply because few of the people involved are paid APA employees. This doesn’t pass the most forgiving smell test.
2. Since the DSM-5 suggestions will all broaden the definition of mental disorder, why should we not worry about diagnostic inflation and the massive mislabeling of normal people as mentally ill?
3. Won’t this diagnostic inflation exacerbate the already rampant over-prescription of psychotropic medications [especially by primary care doctors, especially antipsychotics, especially to kids]?
4. Why should we not worry about the unintended forensic complications of a sloppily written DSM-5 containing suggestions that are obvious targets for forensic misuse?
5. Won’t the many small, needless, and arbitrary changes in DSM-5 complicate future research efforts and make impossible the interpretation of data collected before versus after DSM-5?

^{APA’s response dodges all 5 questions. Perhaps this is because DSM-5 is so fundamentally flawed that it is defensible only by smoke screen. And experience has proven that DSM-5 cannot self correct — its current version is virtually equivalent to the frightening first draft posted in February 2010. The calls for public comment have turned out to be no be more than sham, public relations window dressing with no substantive impact on product. It is by now crystal clear that APA will produce a safe and scientifically sound DSM-5 — only if its users rise up and force it to. Concerned? You can help by signing the petition to reform DSM-5 at http://www.ipetitions.com/petition/dsm5/.}

Drs. Oldham, Kupfer, and Regier are smart people. I doubt they are genuinely confused about what’s being requested or why. My reading of this response to the ACA and the response to the Psychologists was "No!" Likewise, Dr. Frances’ observation ["And experience has proven that DSM-5 cannot self correct — its current version is virtually equivalent to the frightening first draft posted in February 2010"] confirms the time honored adage – the best predictor of future behavior is past behavior. And while Dr. Oldham’s letter is not so embarrassing as the earlier nasty response of Dr. Schatzberg, it’s ultimately little different in meaning, "No!" And so the players in this game are changing, or perhaps broadening. It’s not just the APA DSM-5 Task Force that’s drawing a line in the sand. It’s the APA [American Psychiatric Association] itself that’s stonewalling.

Like many, I resigned from the  APA [American Psychiatric Association] a long time ago. I just didn’t see any way it was representing me, my interests, or my patient’s interests. It was long before Dr. Insel’s declaration that Psychiatry was Clinical Neuroscience [2005], but that’s what it felt like the APA had become before I ever heard the term. The other feeling I had back then was that the APA was directing how psychiatry would be rather than representing the specialty [if I hadn’t already resigned, I certainly would’ve resigned when Alan Schatzberg was president].

I understand why Dr. Frances says, "It is by now crystal clear that APA will produce a safe and scientifically sound DSM-5 — only if its users rise up and force it to", but I wonder if even that will change the current trajectory of the DSM-5. The APA is under the spell of a particular subset of psychiatrists right now. They’ve come into prominence and reached high places during a particular [and peculiar] period that spans their entire career [as it has mine]. It’s essentially all they know [and all they have really ever known] – future directed neuroscience and a pharmaceutically funded focus on psychopharmacology. Their positions as chairmen have been contingent on raising PHARMA money. Their labs have been PHARMA funded. Most have compromised standards by being guest authors or on PHARMA advisory boards. Their departmental and personal finances have been heavily supplemented by PHARMA connections. Their scientific language has been monotonously uniform in its focus. They’ve walked the walk and talked the talk so long that it may be all they really even know. They are themselves as spellbound as the spell they, in turn, cast over the APA and its DSM-5.

So I would add a corollary to Dr. Frances’ "It is by now crystal clear that APA will produce a safe and scientifically sound DSM-5 — only if its users rise up and force it to". A user rebellion will only have the desired impact if at least a few more people in the inner circle of high places in psychiatry and the APA cast the scales from their eyes and join the outcry. Without that, I fear that the inertia of the last generation will keep on keeping on with the DSM-5 and postpone the necessary changes for a short while, until the unsold and unmentioned DSM-5 volumes begin to gather well-deserved dust in the APA’s warehouse…