There is a large Health Affairs article that just became
available online. It criticizes (what
else) the DSM 5. The article and its
initiatives all seem to flow from the conclusion:
"Inadequate interdisciplinary review and collaboration translate into missed opportunities to increase the accuracy of explanations for mental disorders. They also lead to suboptimal care and outcome disparities for millions of patients at a time when dramatic differences in psychiatric diagnosis and treatment rates by sociodemographic status, ethnicity, and geography have undermined public confidence in psychiatry.” (p 7)
"Inadequate interdisciplinary review and collaboration translate into missed opportunities to increase the accuracy of explanations for mental disorders. They also lead to suboptimal care and outcome disparities for millions of patients at a time when dramatic differences in psychiatric diagnosis and treatment rates by sociodemographic status, ethnicity, and geography have undermined public confidence in psychiatry.” (p 7)
I hope that anyone reading this blog knows what the factors
are in the mismatch between psychiatric diagnoses and care. I hope that anyone reading this blog knows
the biases against psychiatry and how that influences the allegations of
overdiagnosis, diagnostic reliability, overprescriptions and conflict of interest that are typically leveled at psychiatrists and their professional
organization. The most obvious example
and a point that seems to be completely lost on these authors is the rationing
of psychiatric services and the resulting fact that most of the diagnostic
disparities that they are complaining about are not due to psychiatrists or the
DSM. I hope that any reader here has also noted my
running commentary about the real causes of “suboptimal care and outcome disparities”. It is directly related to managed care,
pharmacy benefit managers, and the adoption of these same rationing practices
by local, state, and federal governments charged with the provision of mental
health and substance abuse services.
The authors seem to lack an understanding of some of the
basic social processes that they believe to be impacted by the DSM. They cite the New York Times as a source for
the issue of whether the DSM committee backed down on diagnostic revisions that
would have disqualified “half of those who currently receive benefits for
autism spectrum disorders” and various other changes. As a psychiatrist who is intimately familiar
with the disability process, the determination of disability is a political process
at the level of the Social Security Administration. A diagnosis is an entry point but it does not
assure a disability award or even ongoing disability payments. I have seen patients who were hospitalized for
severe problems who did not get a disability determination in their favor. I have seen people who clearly misrepresented
themselves, did not believe they have a mental disability, and who received
disability determinations that they requested.
As far as I can tell, the system is currently set up to favor people
with mental illnesses who have been hospitalized at least three times in two
years. There are companies who
facilitate applications. It generally
takes a series of two or three appeals that can drag out over a year or
two. If it comes to a hearing, those
hearings are uncontested and they are not adversarial in that the government does
not have an attorney present to oppose the application and the decision is made
by a judge and not a jury. The most significant political event in this process
occurred about 15 years ago when the government decided it would not consider
alcoholism and drug addiction a disability.
Prior to that alcoholism was a leading cause of disability in many
states. With all of those political variables
how can a DSM diagnosis be seen as the rate limiting step in that process?
The authors also conclude “Psychiatric conditions result
from a combination of biological and environmental factors”. The arguments that follow suggest that psychiatrists
are basically clueless about these phenomenon.
I did not see George Engel or the biopsychosocial model of illness
referenced. In Engel's seminal 1977 paper
in Science, he directly addressed the
limitations of the biomedical model and changed the paradigm for the future by
proposing a biopsychosocial model. This paper
is dramatic in its intellectual scope and it addresses practically
all of the issues brought up in the Health Affairs article including several
areas that are not addressed such as the experience of the patient. Engel also addressed the issue of “When is
grief a disease?”, a popular current DSM critique:
“…Hence the physician’s basic professional knowledge and
skills must span the social, psychological, and biological for his decisions
and the actions on the patient’s behalf involve all three. Is the patient suffering normal grief or
melancholia? Are the fatigue and
weakness of the woman who recently lost her husband conversion symptoms, psychophysiological
reactions, manifestations of a somatic disorder, or a combination of
these. The patient soliciting the aid of
a physician must have confidence that the MD degree has indeed rendered that
physician competent to make such differentiations.”
A reference to Engel would seem appropriate but it detracts
from the authors’ contentions that physicians seem to need to have their
biopsychosocial horizons broadened and acknowledging that a physician discussed
this definitively 35 years ago would detract from their argument.
The authors more direct arguments about the role of “social
and institutional influences on diagnosis” can be similarly addressed. Although they don’t acknowledge the DSM, they
discuss post traumatic stress disorder as an example of environmental exposure. They
cite evidence gathered in the psychiatric literature as their proof. In fact, any psychiatric evaluation should
contain a formulation section that considers social, biological, and
consciousness based factors in the overall evaluation of the person seeking
help. This is nothing new and every
competent psychiatrist is trained to do this.
The now abandoned oral Board exam, used to test these skills. The idea that these factors are relevant to
psychiatric diagnosis have been taught to psychiatrists for decades. Do we really need to learn that from a panel of social experts who don't talk with people about that information every day like we do?
The idea that social
context, is a relevant factor has
also been obvious to psychiatrists for a long time. Psychiatrists are routinely asked to evaluate
and treat patients from various socioeconomic and cultural groups and
frequently work with interpreters in the process. There is no basis in fact for their
speculative comment that “Identifying and understanding the causes of
diagnostic disparities can lead to improved diagnostic criteria and their more
accurate application.”
On the issue of institutional
and policy factors the authors also miss the mark. They make the previous mistake about
diagnosis and Social Security disability by suggesting that a specific
diagnosis results in a disability check.
They do not point out how the Social Security process rather than a DSM
diagnosis may be more important in the issue of disabilities for mental health.
Interestingly they are concerned about the “major consequences for payers and
patients" and reference a study looking at the prescription of atypical
antipsychotic medications for children.
They ignore the fact that the actual treatment of mental illnesses are
outside of the purview of the DSM and that overprescription (if this is
actually overprescription) is a widespread problem that extends well beyond the
field of psychiatry. As is the case with
all critics of psychiatry and the DSM, they give a pass to the real causes of
systemic poor treatment and a focus on medications rather than psychosocial
therapies and that is the managed care industry and its supporters at all
levels in the government.
Their final focus on publicity
and marketing is certainly not a problem specific to psychiatry. It is also a process that is not DSM
dependent. Restless leg syndrome or
insomnia do not need to be in the DSM to end up being treated on a large scale
by primary care physicians. All it takes is a pharmaceutical company web site with a checklist. They provide
no insight into why the political process of direct-to-consumer advertising as determined
by lobbyists, politicians, and the associated exchange of money should be part of a DSM oversight process.
The authors proposed Psychiatric
Diagnosis Review Body and its potential benefits are equally speculative. Their idea that there would be “greater
sophistication” in the explanations of mental illness is doubtful, especially
considering the impact that Engel’s biopsychosocial model has had on both the
field and DSM development. Their idea
that the work of a review body would “heighten mental health practitioners’
awareness of population level differences in diagnoses, in some instances
improving their ability to tailor diagnoses to patient’s demographic
characteristics and cultural backgrounds…” is also problematic. First off, the DSM is written for
psychiatrists and a psychiatric diagnosis and formulation is much more than looking
at a list of symptoms that possibly identifies a person as being a statistical
outlier in a group. Any person can pick
up a copy of the DSM and presume to make a "diagnosis" based on these criteria,
but that is not a psychiatric diagnosis.
Secondly, cultural, demographic characteristics, and demographic factors
have already been incorporated into psychiatric evaluations for decades. An even greater question is what broad scale
social data would add to the evaluation of the individual patient given the biases
that are usually present in those studies.
The authors suggest that the incorporation of feedback from
the review body would “increase public confidence in the manual and psychiatry
as a medical profession”. The single
most important factor that would enhance psychiatry’s image would be the
recognition that rhetorical negative arguments against the profession abound
and need to be corrected. That could
start by recognizing what psychiatrists actually do and what a DSM is actually
used for. It would also take a critical
look at why 20 years of rationing of psychiatric services by the managed care
industry and the government is the single largest factor in why these services
have deteriorated and now operate on the premise that getting people on one
medication or another is the best way to treat mental illness. The authors in this case banter about million
and billion dollar amounts that are typically used to suggest the impact of the
DSM or significant conflicts of interest in psychiatry. Nobody is focused on the fact that the
managed care industry makes far more money than that by denying medical
care. Psychiatric services make up a
disproportionately large amount of denied care.
If you are really interested in improving the care of people
with mental illness in this country it would seem logical to attack those who routinely
deny them care and interfere at all levels with the provision of care rather than those providing the care and trying to improve it. That is the most important social problem
affecting the provision of mental health services and access to psychiatry. Social scientists seem to be as disinterested in that fact as the average journalist.
George Dawson, MD, DFAPA
Hansen HB, Donaldson
Z, Link BG, Bearman PS, Hopper K, Bates LM, Cheslack-Postava K, Harper K,
Holmes SM, Lovasi G, Springer KW, Teitler JO.
Independent Review Of Social And
Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions.
Health Aff (Millwood). 2013 Apr 24. [Epub ahead of print] PubMed PMID:
23614899.
Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.
Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.
George L. Engel, MD. JAMA.2000;283(21):2857.
doi:10.1001/jama.283.21.2857
