As anyone reading the newspapers has heard, the DSM-5 went on sale earlier this year amidst a cacophony of DSM bashing and bashing of the profession in general. The most vehement critics also exhorted the public to not buy this evil book that would lead to the squandering of billions of healthcare dollars and leave millions hopelessly misdiagnosed and taking expensive unnecessary drugs. In some cases that I have recorded on this blog the criticism was even more extreme. Now that the DSM-5 has been out for several months I asked myself what the outcome of all of that bad press has been? Like thousands of my colleagues, I have picked up a copy and glanced at it from time to time. It certainly has not lead to any revolution in psychiatric practice or changed anyone's clinical interviewing or diagnostic process. In fact I have talked with many psychiatrists in the past several months and none of my conversations has touched on the DSM-5. What are the facts of the release after all of the pre-release spin?
First of all, the predicted apocalypse has not happened. I should say the apocalypse happened but it was 30 years ago when the managed care industry essentially converted mental illness into "behavioral health" and began to restrict access to psychiatric care, inpatient and medical care, psychotherapy, and certain medications to people with severe mental illnesses. The predicted apocalypse in response to the DSM-5 did not happen because as I have been saying all along, the DSM has never been the problem. Mental health care can be denied as easily on the basis of a DSM-5 diagnosis as a DSM-IV diagnosis. A diagnostic manual is partially relevant only for people who are trained to use it.
That said, is there any way to estimate whether people are buying it or not? I heard a sales estimate e-mailed by a colleague that suggested brisk sales, but did not have permission to quote him so I started to look for public sources of data on DSM-5 sales. I went to the usual New York Times Bestseller List and could not find it listed. I could not really find any academic books listed there so I wonder if there is not another list. I thought that Amazon would be the next logical stopping point and I did find some data there. I was looking for data in number of units actually sold and I could only find that as proprietary data that somebody would sell to me. I did find it as # 8 in Best Sellers of 2013 so far. This link shows it has been in the Top 100 books for 167 days but that it has fallen to the number 4 position. Interestingly the Publication Manual of the American Psychological Association had been on the same list 8 times as long. I also found it in a sequential list of DSM-5 products and related variants including 2 books about the DSM-5 by Allen Frances, MD. It made me think about obvious conflict of interest considerations in the psychiatry criticism industry that are never mentioned when they get free press. If somebody can suggest that I have been getting a free lunch from a pharmaceutical company when I haven't seen a drug rep in over 25 years, they should at least point out that somebody can currently make money - possibly even a good amount of money by criticizing psychiatry regardless of whether or not that criticism is remotely accurate.
That is all I have so far. If you have reliable public data on the actual sales of this manual and would like me to post it here, please send me the information. I have requested the actual sales figures in an APA forum but I doubt that anyone will provide them to me. The APA is a very conservative organization and I doubt that they would want you to see those sales figures posted here, even if if this is probably the only public forum that takes a very skeptical look at all of the critics of the DSM-5 and psychiatry in general.
George Dawson, MD, DFAPA
I don't think that APA is hiding the sales figures. They should be readily available from the APA Budget and Finance Committee. Find out which APA members are on the Commitee. I believe Alan Schatzberg chairs it.
ReplyDeleteThanks for the tip Barry. I am working on it right now.
DeleteI found the most impressive thing about the DSM-5 was that, after all the hoopla, how surprisingly little it had really changed from the DSM-IV.
ReplyDeleteThe personality disorders part, which is my particular interest, is basically identical, with a chapter in the back of the book discussing the more dimensional model that everyone in the Association for Research in Personality Disorders had been bickering about for the last several years.
I agree and in fact it was predictable from all of the pseudocontroversy leading up to the release. In my current focus on addiction, the criteria for substance abuse and dependence were combined under substance use disorder, the recurrent legal problem criteria was eliminated and craving became a criteria. Very subtle change but on the other hand there is a long and detailed research history on the theory and more recently neurobiology of craving. These subtle changes are the sorts of things important to eggheads and clinical psychiatrists but not many other people. The pre-release hype suggested that the DSM-5 was an insult to most people.
DeleteDr. Allen,
ReplyDeleteI don't consider it a plus that very little had changed from DSM-4 because that was badly flawed to begin with.
As Dr. Ghassemi at Tufts has pointed out, the original Washington St Louis group during DSM-3 recommended about two dozen diagnoses as taxonomically valid using the Robins and Guze paper criteria. 90% of the diagnoses in DSM are the result of diagnostic inflation based on quasireliability studies without any attention to validity, and utmost attention to utility and reimbursement.
Can you scientifically defend "Mood Disorder NOS"? It's self-contradictory. A category for things that don't fit into a category.
More proof of diagnostic inflation. Take Major Depression. Two bits of evidence here, the high rate of remission with placebo and not much higher with SSRIS, the other is the plethora of articles about comorbidity. Isn't this proof that we are diagnosing a lot of self-limited conditions?
I know you don't like the consternation about DSM, but do you think it is taxonomically valid to diagnose someone with Major Depression on the 15th day after the lost a child in an accident? I don't. But you disagree don't be surprised to find those placebos working amazingly well and thousands more articles on comorbidity.
Or is it all about getting paid and Karl Popper, Paul Meehl and their theories be damned?
I'm not for diagnostic anarchy, but how about let's just start with the Feighner critieria minus homosexuality and work out from there once we know a little more? Focus on the pure pathology first.
I have an update for readers of this post. I was just informed that DSM-5 sales as of one month ago was 510,000 copies. On the Amazon best seller list of 2013 it was number 12, just ahead of the perennial favorite Publication Manual of the American Psychological Association at number 18. Please note the date of this post.
ReplyDeleteIf DSM 5 wasn't all that much of a change and clinicians tend to just glance at, what was it for? To make money for the APA?
ReplyDeleteI think the number one reason for a DSM 5 was for the clinicians and researchers who realized the previous DSM had been there a long time and needed to be updated. It also allowed for a better format for rapid updating in an online version. Nowhere in the press did I see mention of the fact that there are researchers out there working on issues relevant to diagnostics and phenomenology whether there is a new DSM or not. The idea of a new DSM brings them together to discuss their findings and thinking about these problems. That is a story worth paying attention to, but of course nobody in the press did.
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