If you think I’ve been underproducing blog posts lately, you can lay the blame at the doorstep of Rick Bukata and Jerry Hoffman of Primary Care Medical Abstracts. Being a lazy cuss, I often don’t know that an article of interest has been published until they include it in their monthly literature updates, and their January edition was quite late in coming out. But when it arrived it did include two papers that shed a bright light on a topic we’ve addressed in the past, such as:
http://brodyhooked.blogspot.com/2009/07/more-on-psychiatrys-dsm-v-mess.htmlThe first article is an opinion piece that fires a broadside at the new DSM-5 and the "psychiatric oligarchs" who wrote it:
http://www.bmj.com/content/344/bmj.e3135?view=long&pmid=22551806Scottish GP Des Spence notes the new CDC figures showing that based on the expansive way we now define mental illness, about a quarter of the US population is mentally ill. Now, if a group had a tiny sliver of scientific curiosity, this statistic would be a matter of dismay and demand immediate and thorough study – either something horrible has been added to the US water supply, or else the way mental illness is defined and counted has become totally disconnected from any form of medical reality. Yet the psychiatric community can apparently look on these figures with satisfaction.
Spence lays the blame clearly at the feet of conflict of interest, noting that 75% of the authors of DSM-5 are awash in COI. Spence avers that the new, broader definitions of mental illness in DSM-5
"defy common sense and will serve only to undermine psychiatry’s professional standing. It is yet more industrial mass production psychiatry to serve the drug industry, for which mental ill health is the profit nirvana of lifelong multiple medications."By way of illustrating what this means, we can turn to the second article:
http://onlinelibrary.wiley.com/doi/10.1002/phar.1141/abstract;jsessionid=40498050C908CBC4C63E2D01A0C0B731.d03t03Dr. Herschel Jick and colleagues from Boston University looked at how methylphenidate (Ritalin) was prescribed for children aged 5-14 in the US vs. Britain. They found out by the way that equivalent supplies of the drug cost about 4 times more in Britain than here. But much more worrisome is the evidence that more than 4 times as many kids in the US were being prescribed this drug, supposedly for attention deficit disorder, than is true in the UK. It seems that our threshold for deciding a kid has a major mental disorder, with all the implications of carrying that label for life, is much lower than it ought to be. And Spence for his part notes that in the new DSM-5 the criteria for diagnosing ADHD are loosened substantially.
I’ll go back to my previous post on Robert Whitaker’s important book–
http://brodyhooked.blogspot.com/2010/05/whitakers-anatomy-of-epidemic.html
–as well as to my previous post on the antipsychiatry movement:
http://brodyhooked.blogspot.com/2009/01/living-up-to-worst-expectations.html
–to remind anyone just joining us that I have not joined the scientologist crazies and that I agree with Whitaker that there is a group of folks (he estimates about a fifth of those now taking psychiatric medications in the US) who suffer miserably without their meds and who are vastly more functional with them. But when we decide that a quarter of the US population is mentally ill and probably ought to be on drugs, then what used to be a thoughtful and helpful medical specialty seems to have turned into nothing more than a marketing agency for Big Pharma.What to do? There is probably a simple step that could well be effective. We usually figure that a medical specialty group can be trusted to tell us how to diagnose conditions that fall within their specialty. So, for instance, if cancer specialists tell us that such-and-such is what make a cancer of the prostate Stage 2, then other specialists use those criteria and the Stage 2 label for that form of disease. So it has been logical that other specialties that treat patients with mental illnesses, such as family physicians, pediatricians, internists, etc., have routinely used the DSM’s earlier editions as their guide to diagnosing and labeling mental illness.
Therefore, the American Academy of Family Physicians, the American College of Physicians, and all other specialty groups ought to declare officially that they reject DSM-5 and will advise their members not to employ its terminology or criteria. Unless and until the American Psychiatric Association can come up with a scientifically more valid manual created by people free of conflicts of interest, they should not be able to foist their commercial product (off which they make huges sums in sales) on the wider medical community.
Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional [eg, quantitative] approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses [ie, “not otherwise specified” disorders] from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician — not to a psychiatrist — when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention. Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians…
The most important next challenge is identification of DSM-5 criteria of particular relevance to specialties outside of psychiatry. Even though the criteria for the most common DSM disorders were written with the general medical practitioner in mind, the American Psychiatric Association is developing a collaborative approach to identifying the disorders most frequently seen in primary medical care settings and the particular way in which those disorders are likely to present in such settings — an emphasis to make the DSM-5 of greater value to all of medicine… [link] February 2013
As a psychiatrist, it’s embarrassing enough what happened in organized psychiatry. But as a physician, it’s worse – and we are physicians. When psychiatry discarded psychotherapy back in 1980, it seemed to have forgotten that one of our principle tools was helping people tell the truth to themselves by confronting rationalizations and other mechanisms that disguised more unsavory motives. The DSM-5 is clearly driven by commercial and self-serving forces that are patently obvious even to the untrained ear. And it has been going on so long that we seem to have all but forgotten that we used to be the group that tried to keep people honest – free of the wages of spin.
I went to my blog to write a post and Dr Brody’s post was the top entry as a tie in to my site. Read it and was enlightened.
Oh, and by the way, your comment near the end, “When psychiatry discarded psychotherapy back in 1980, it seemed to have forgotten that one of our principle tools was helping people tell the truth to themselves by confronting rationalizations and other mechanisms that disguised more unsavory motives.”, very well said. It is about truth, not just getting “better”.
I think we are forgetting that part of the wide discard of insight-oriented psychotherapy was that it wasn’t very accessible and not all that helpful for a lot of people who could access it, truth or not, and it did not take training as a physician to be a therapist (even Freud advocated for non-physician analysts). Perhaps ending up with truth AND getting “better” is superior to just one of those, people in distress do not seek expensive professional help with already not great odds of good outcome for just truth.
testing