The Latest Proclamation by Allen Frances

Just when you think that Allen Frances has run out of editorial venues for his anti DSM5 critiques another one pops up.  This time it is in the Annals of Internal Medicine.  This is a note about that process before I get into addressing his repetitive critiques.  The Annals is a respected medical journal.  For a number of years I was an ACP member and subscribed to it myself.  Why would the Annals go along with publishing an editorial piece that is basically a rehash of what has been published in the New York Times and the Huffington blog and who knows where else?  There is really precious little science involved.  I think the only logical explanation is that the staff of the Annals has jumped on the popular bias against psychiatry that has been widely noted in the press by Claire Bithell and her group that studies these issues.  I am not a current subscriber to the Annals but the question is whether there was equal time for rebuttal.  If not is this professional bias against psychiatry?

Probably the best way to address this rehash of old criticisms is to link up to previous blog posts here where that occurs.  Beginning in paragraph one Dr. Frances cites a famous study about pseudopatients as though it has some applicability to the issue of “unreliable and inaccurate” psychiatric diagnosis.  He cites this study as if it is somehow relevant to the problem.  All of the considerable scholarship refuting this study as meaningful by various authors including Spitzer and Kety is ignored.   Using this as a premise for a scholarly article on the validity of psychiatric diagnosis should raise an eyebrow or two, but on the other hand I doubt that there is anyone on the editorial board at this Internal Medicine journal who is familiar with this literature.

The issue of diagnostic inflation is a frequent critique used by Frances and others to suggest that this invalidates the DSM5.  Most people are very surprised to learn that compared to previous editions and the ICD-10 this is really not an issue.  The previous blog post illustrates that compared to the ICD-10, the possible increase in diagnostic categories in the DSM is trivial.  The increase in the number of codes for a knee fracture alone approximates the total codes in the DSM!  Contrary to his description of “holding the line” with DSM-IV diagnoses – the data presented in that post shows that the DSM-IV added twice as many diagnoses as the DSM5 will.

Dr. Frances uses the “no bright line” approach to say that there is no way to separate the worried well from people with disorders.  There certainly is no written “bright line” in the DSM.  Every DSM has a section with qualifying statements about its use and that fact that diagnostic criteria alone are not sufficient.  A psychiatric diagnosis, especially a diagnosis made by psychiatrists in the same group with the same focus is very consistent and it is a reliable marker of illness severity.  Professional judgment is required.  The “no bright line” issue is not a problem that is unique to psychiatry.  It is omnipresent in general medicine with regard to chronic pain diagnoses, chronic pain treatment, and in the overprescription of pain medications and antibiotics.  The overprescription of antibiotics has been identified as a problem by the Centers for Disease Control (CDC) for 20 years and recent authors suggest that minimal progress has been made.  It seems that other specialties are subject to the “fallible subjective judgments” suggested in this article.

Another implicit myth used by Dr. Frances and other critics of psychiatry is that there is some magical diagnostic process that occurs in medicine and surgery that makes them better than psychiatric diagnoses.  What happens when we test that theory by looking at the reliability of general medical diagnoses?  Looking at that data, it is clear that the published reliability data from medicine and surgery is no better than the frequently criticized data from psychiatry even when objective medical tests are used.  Practically everyone I know has a favorite story about a misdiagnosis and/or ineffective treatment of a medical or surgical problem.  That evidence does not support the contention that psychiatry is somehow less accurate or effective than the rest of medicine.  Some medical specialties used similar descriptive techniques even when they have numerous biological markers of the illness.  The other elephant in the room on this diagnosis issue is medically unexplained symptoms.  The studies of all patients coming in to a clinic setting suggest that 30%  do not get a diagnosis to explain their symptoms.  These patients often get multiple tests looking for a cause for their problem.  This is by far the most significant problem that I hear from relatives, acquaintances, and the public in general.  If nonpsychiatric medical diagnoses are supposed to be highly accurate based on biological tests – a substantial number of people never actually experience that.

On the fuzzy diagnosis in psychiatry critique, a common theme here is to go after the bereavement exclusion and suggest that normal bereavement will be treated like depression.  I have an extensive response to this when it was posted in a newspaper article and invite any interested reader to look at the previous blog post and the fact that this approach to grieving patients who come to the attention of psychiatrists has been written about for over 30 years (see last 5 paragraphs at link).  Practically every point in this section of the editorial can be disputed but the point of the article is not a scientific review, it is basically a selection of comments to support a specific viewpoint.

To Dr. Frances credit he references an excellent meta-analysis by Leucht, et al on how the results of psychiatric treatment are as good or better than the results of other medical specialties.  He is silent on how that occurs if psychiatric diagnosis is so unreliable and inaccurate.  How is it possible to get results that good compared with other specialties?  Maybe it is because as I have just suggested, the “special problems” in psychiatric diagnosis are really general problems that are shared by all medical specialists?

The criticism is less focused in the final paragraphs with some commentary on style points about the DSM political process, the issue of conflict of interest focused on publishing profits, and the idea that the APA should submit the DSM to oversight by a broad coalition of “50 mental health associations”.  Let me take the last point first.  There are a number of other diagnostic approaches and manuals that have been completed by coalitions of several other mental health organizations.  With the number of different approaches, I would encourage any organization to publish their own approach to the diagnosis of mental disorders.  Contrary to the rhetoric suggesting that there is a DSM monopoly, nothing could be further from the truth.  The entire text of the World Health Organization’s (WHO) ICD-10 is available free online.  The Mental and Behavioral Disorders section of the ICD-10 gives detailed descriptions of each disorder.  The detailed research criteria for ICD-10 can be purchased for about ¼ the cost of a DSM5.  It seems to me that there is a marketplace of ideas and plenty of competition.  If I was not a psychiatrist with an interest in reading about developments in my field, I would not be compelled to purchase a DSM5.  I would probably take a few courses in the changes to DSM-IV and stick with that for a while.

On the issue of submitting the DSM5 to outside groups there are several compelling reasons why that would not be a good idea for most psychiatrists.  Some critiques have suggested that psychiatry should be open to forced collaboration by others based on previous relationships.  Over the span of my career, I have noted that there is often an adversarial approach by other organizations rather than an affiliative one.  And why wouldn’t there be?  This is the United States and everyone here is familiar with the competitive and politicized atmosphere.  It seems like that has been left out of the equation when charges of “conflict of interest” are leveled at the APA in the area of publishing a DSM.  A recent critique of the DSM5 also suggested broader collaboration with social scientists and I critique that article here.  The political slant of all of these articles is that the APA needs the input of others to improve descriptive psychiatry.  Including that in an article that has a basic thesis that: “We will be stuck with descriptive psychiatry for the forseeable future.” (line 27-28) being a negative is inconsistent.  If anything Dr. Frances seems to be suggesting that we should be moving more to the biomedical side and  distancing ourselves from the social scientists.  The bottom line here is that the DSM5 is a diagnostic guideline for psychiatrists to use in clinical practice.  It is not synonymous with a psychiatric diagnosis and it is used at some level by psychiatrists to understand mental disorders.  It is not designed for anyone to read and act like a psychiatrist and it has nothing to do with people who do not have psychiatric problems.  It is not a “Bible” like the New York Times suggests.  It is a tool for psychiatrists and if you are not a psychiatrist there may be no reason for you to buy it or even think that it is relevant to you.

On the issue of Dr. Frances serial DSM5 critiques - this seems like a war of attrition to me.  Dr. Frances has an infinite number of venues that are quite willing to publish his very finite and repetitive criticisms of the DSM5 and the associated process.  Outside of myself – there appears to be nobody else including the American Psychiatric Association who is willing to offer the obvious counterpoints.  He has more time on his hands and many more connections than I do.  So in terms of sheer volume I guess this is a Pyrrhic victory of sorts.  I will have to be content with expressing the opinion of a psychiatrist who practices real psychiatry,  making diagnoses and helping people every day and knowing that my results are on par with anybody else in medicine and that there is nothing random about it.

George Dawson, MD, DFAPA

Even more DSM bashing - is it a fever pitch yet?

Just when you think you have seen it all, you run into an article like this one in The Atlantic.  A psychotherapist with a long antipsychiatry monologue.  It is written in interview format with psychotherapist Gary Greenberg as the discussant.  I thought it was interesting because the title  describes this diatribe as the "real problems" with psychiatry.  Of course what he writes about has nothing to do with the real problems that specifically are the rationing and decimation of psychiatric services by managed care companies and the government.  The entire article can be discredited on a point by point basis but I will focus on a few broad brush strokes.

The author here spins a tale that the entire impetus for a diagnostic manual and a biomedical orientation for psychiatry is strictly political in nature and it has to do with wanting to establish credibility with the rest of medicine.  That is quite a revision of history.  Psychiatry pretty much exists now because psychiatrists would take care of the problems that nobody else wanted to.  I have immediate credibility when another physician is seeing a person with a mental illness, they don't know what to do about it, and I do.  It is less clear today, but psychiatry professional organizations were asylum focused and the goal was to treat people in asylums initially and then figure out a way to get them back home.  Part of the psychiatric nosology was based on the people who would get out of asylums at some point and those who did not.  The credibility of psychiatry has nothing to do with a diagnostic manual.  It has to do with the fact that psychiatrists have a history of treating people with serious problems and helping them get well.  There is no discussion of how the numbers of people institutionalized in the 1950s and 1960s fell to the levels of current European levels as a result of psychiatric intervention that included the use of new medications but also a community psychiatry movement that was socially based. (see Harcourt Figure II.2)

The author uses the idea of "chemical imbalance" rhetorically here as further proof that psychiatrists are using a false premise for political purposes.  He presumes to tell his readers that during the time he is giving the interview there is some psychiatrist out there using the term chemical imbalance to convince a patient to take antidepressants.  Since I have never used that term and generally discourage it when patients bring it up, I wonder if he is right.  Any psychiatrist trained in the past three decades knows the situation is much more complex than that.  Eric Kandel describes the situation very well in his 1979 classic article on "Psychotherapy and the Single Synapse".  Any antipsychiatrist using "chemical imbalance" against psychiatry in a rhetorical manner suggests that there is no biomedical basis for mental disorders.  There should be nobody out here who believes that is true and in fact this article acknowledges that.

The basic position here is to deny that anything psychiatric exists.  Psychiatrists  don't know what they are doing.  Psychiatrists are driven by the conflict of interest that nets them "hundreds of millions of dollars".  He doesn't mention how much money he makes as an outspoken critic of psychiatry.  He tries to outflank his rhetoric by suggesting any psychiatrists who disagrees with him and suggests that it is typical antipsychiatry jargon is "diagnosing him".   He doesn't mention the fact that antipsychiatry movements are studied and classified by philosophers.

I think the most revealing part of this "interview" is that it appears to be orchestrated to enhance the author's rhetoric.  The evidence for that is the question about "drapetomania" and implying that has something to do with coming up with DSM diagnoses and the decision to drop homosexuality as a diagnostic category.   That is more than a stretch that is a clear distortion and of course the question is where the interviewer comes up with a question about "drapetomania".  I wonder how that happened?

This column is an excellent ad for the author's antipsychiatry work.  Apart from that it contains contains the standard "chemical imbalance" and psychiatric disorders are not "real illnesses".  To that he adds the conflicting positions of saying there appear to be biological correlates of mental disorders but they would never correlate with an existing diagnosis and the idea of a chemical imbalance metaphor is nonsense.  He uses colorful language to boost his rhetoric:  "They'll (those wacky psychiatrists - my  clarification) bob and weave, talk about the "living document," and unleash their line of bullshit." 

His conclusory paragraph and the idea to "take the thing (DSM) away from them" has been a common refrain from the DSM critics.  In fact as I have repeatedly pointed out, there is nothing to stop any other organization from coming up with a competing document.  In fact, sitting on my shelf right now (next to DSM-IV) is a reference called the Psychodynamic Diagnostic Manual.  It is listed as a collaborative effort of six different organizations of mental health professionals.  It was published 12 years after the last edition of the DSM - it is newer.  I have texts written by several of the collaborators of this volume.  When I talk with psychiatrists from the east coast, they frequently ask me about whether or not I am familiar with the volume.   My point here is that if the author's contentions about the reality basis of DSM diagnoses are correct, it should be very easy to come up with a different system.  I encourage anyone or group of people to develop their own diagnostic system and compete with the DSM.

So the last minute attacks on psychiatry with the release of the DSM seem to be at a fever pitch.  The myth of the psychiatric bogeyman is alive and well.  Add The Atlantic to the list of uncritical critics of psychiatry.

George Dawson, MD, DFAPA

1.  Hope Reese.  The Real Problems with Psychiatry.  The Atlantic.  May 2, 2013.

2.  Bernard E. Harcourt.  From the asylum to the prison: rethinking the incarceration revolution.  The Law School, University of Chicago, 2007.

3.  Psychodynamic Diagnostic Manual (PDM).  A collaborative effort of the American Psychoanalytic Association, International Psychoanalytic Association, Division of Psychoanalysis (38) of the American Psychological Association, American Academy of Psychoanalysis and Dynamic Psychiatry, National Membership Committee on Psychoanalysis in Clinical Social Work.  Published by the Alliance of Psychoanalytic Organizations.  Silver Spring, MD (2006).

4.  Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37. PubMed PMID: 40128.

Nature Takes A Shot at DSM5 – Spectrums Only Get You So Far

"The Catholic Church changes its pope more often than the APA publishes a new DSM." (reference 1)

I was disappointed to see another shot at the DSM, this time on my Nature Facebook feed.  I suppose with the impending release it is a chance to jump on the publicity bandwagon.  I will jump over numerous errors in the first paragraph (David Kupfer – modern day heretic?!) and get to the main argument.  The author in this case makes it seem like seeing psychopathological traits on a spectrum is somehow earth shaking news and yet another reason to trash a modest diagnostic manual designed by psychiatrists to be used as a part of psychiatric diagnostic process. 

In evaluating this article the first question is the whole notion of continuums.    The idea has been there for a long time and this is nothing new.  Just looking at some DSM-IV major category criteria like major depression, dysthymia, and mania and just counting symptoms using combinatorics you get the following possibilities:

Major depression - 20 C 5 = 15,504

Manic episode - 15 C 3 = 455

Dysthymia - 2 C 10 = 45

Mixed - 20 C 5 + 15 C 3 = 15,959

That means if you are following the DSM classification and looking just at the suggested diagnostic combinations you will be seeing something like 16,004 combinations of mood symptoms just based on a categorical classification.  Superimposed reality can expand that number by several factors right up to the point that you have a patient who cannot be categorically diagnosed. If you add all Axis II conditions with mood sx - there is another large expansion in the number of combinations.  The sheer number of combinations possible should suggest at some point that the discrete categories give way to a frequency distribution.  The only problem of course (and this is lost or ignored by all managed care and political systems) the clinician is treating an individual patient with certain problems and not addressing the entire spectrum of possibilities.  The other reality is that if you put a point anywhere on the spectrum including the Nature blog's  mental retardation-autism-schizophrenia-schizoaffective disorder-bipolar and unipolar disorder spectrum - you essentially have a categorical diagnosis.

In a recent article, Borsboom, et al use a graphing approach to show the relationship between the 522 criteria (simplified to 439 symptoms) of 201 distinct disorders in the DSM-IV.  The authors demonstrate that these symptoms are highly clustered relative to a random graph and go on to suggest that their network model currently account for the variance in genetics, neuroscience, and etiology in the study of mental disorders.  Their figure below is reproduced in accordance with the Creative Commons 3.0 license. (click to enlarge).

 For the example given by the author’s example – schizophrenia with obsessive traits, we still need to make that characterization in order to proceed with treatment.   The diagnostic categories “schizophrenia” and “obsessive compulsive disorder” and “obsessive compulsive personality disorder” are still operative.  What does saying that there is a “continuum” or “spectrum disorder” add?   In initial evaluations psychiatrists are still all looking for markers of all of the major diagnostic categories and listing everything that they find.  The treatment plan needs to be a cooperative effort between the psychiatrist and patient to treat the problems that are affecting function and leading to impairment.  The idea that there will be a magical genetic and brain imaging test that will result in a “proper clinical assessment” at this point is a pipe dream rather than a potential product of a diagnostic manual.  The limitations of the spectrum approach are also evident in this article that points out the failed field trials attempting to use a dimensional approach for personality disorders.

George Dawson, MD, DFAPA

1.  Adam D. Mental health: On the spectrum. Nature. 2013 Apr 25;496(7446):416-8. doi: 10.1038/496416a. PubMed PMID: 23619674

2.  Borsboom D, Cramer AO, Schmittmann VD, Epskamp S, Waldorp LJ. The small world of psychopathology. PLoS One. 2011;6(11):e27407. doi: 10.1371/journal.pone.0027407. Epub 2011 Nov 17. PubMed PMID: 22114671

Crickets from the APA

"The best way to predict the future is to create it." - Peter Drucker

The annual convention is approaching and the American Psychiatric Association (APA) has decided to train a few psychiatrists from each district branch to teach about the new DSM5.  They think that is sufficient to fill the demand from organizations and groups who want assistance with DSM5 training and implementation.  They also think that the threat of litigation is enough to protect the DSM copyright and prevent other self declared trainers from going around the country and training people about the DSM5.  That is more critical than you might think.  Let me explain why both of these thoughts are problematic wrong and describe a more optimal course of action that could still be implemented before the May convention.

First of all let me say that the ideas I am posting here are not new.  I have inquired directly from the APA as a member both at their Washington Offices and through my District Branch (DB).  The lack of response prompted the “Crickets” title from the APA because cricket chirping is about all I am hearing about any initiative other than the APA’s original plan.  There are many sources of failure possible by restricting the training.  The obvious one is that psychiatrists are busy.  The failed billing and coding system generally means that psychiatrists are seeing a lot of patients and spending even more time on billing, coding, and documentation.  That leaves very little time each week to study for recertification exams, train future psychiatrists and medical students, and participate in other professional activities.  Given how thin psychiatrists and other physicians find themselves spread, it might be reasonable to have a bureau of trained DSM5 experts at each DB to cover the potential demand.

I first got interested in this issue when a large health care organization asked me about the availability of consultants to assist them in their nationwide implementation.  The DSM IV is currently implemented in their electronic medical record (EMR).  Several calls directly to the APA did not produce any results.  I identified myself as a member and that did not make a difference.  I contacted my excellent DB Executive who I had worked with during my term of being the DB President.  She is extremely knowledgeable and widely networked within the organization.  The question I proposed was whether the APA would consider opening up the convention session to all psychiatrists through the DB and certifying anyone who has taken the course.  Still no response.

Absent the response I have the following suggestions about how to train DSM5 trainers in the interest of the APA and its mission and preserve the copyright integrity of the DSM5:

1.  Expand the training in May to all DBs and to as many psychiatrists as want to take the training.

 

2.  Provide password access to all of these psychiatrists to the DSM5 web site for the purpose of ongoing learning.  The DSM5 site was quite good in providing the rationale for suggested changes and prospective trainers could benefit from ongoing access to this material.

3.  Provide educational materials (PowerPoints) to all of the trainers through access to a training web site.

4.  Develop a course specific to administrators and companies who need IT implementation information and have that readily available.

5.  License DSM5 to corporations in the same way that psychiatrists with online subscriptions can access it.  UpToDate has provided a good example of the continuously updated online reference rather than serial textbooks being the direction forward.  There should be no need for update cycles and massive political events to herald updates.  The DSM and all psychiatric guidelines need to be systematically reviewed and updated if APA technology is to be seen as the definitive reference for the biomedical diagnosis and treatment of major mental disorders.  Updating every 10-20 years will not survive in the day of Internet technology.  There is also a lot less drama involved when UpToDate updates its content.  That is consistent with being a resource for physicians and by physicians.  

All of these recommendations can be done and anything less than following through on these recommendations leaves the APA seriously compromised and not competitive in the future.

George Dawson, MD, DFAPA

Moralizing About Psychiatry and the Limits of Philosophy

This article came to my attention this week from the New York Times blogs.  The author identifies himself as a philosophy professor and scholar who is an expert in French philosophy.  He presents some viewpoints of Foucault and others to criticize the DSM and of course the clinical method in psychiatry.  I will be the first to admit his initial argument is confusing at best and is based on Foucault’s observation: “What we call psychiatric practice is a certain moral tactic….covered over by the myths of positivism.”  Indeed, what psychiatry represents as the “liberation of the mad” (from mental illness) is in fact a “gigantic moral imprisonment.”  In the next sentence the author  acknowledges: "Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration."

From my viewpoint whenever an author’s rhetoric outstrips the truth it means that at the bare minimum any observer should be skeptical of the biases involved and these appear to be the common themes that we see from antipsychiatrists.  It does not take the author very long to develop that angle:

“Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be  society’s way of controlling what it views as immoral or otherwise undesirable behavior.”

He gives examples of the previous treatment of homosexuality and women and uses this as a platform for suggesting “….there’s no guarantee that even today psychiatry is free of similarly dubious judgments.”  With no credit given to Spitzer’s role in both the DSM and eliminating homosexuality as a mental illness back in the 1970’s (where is the rest of America on that issue even today?) he latches on to the bereavement exclusion as the latest example of how psychiatrists are trying to dictate how people live and how various nonphysicians are better equipped to decide about whether the bereavement exclusion should be left in place.  Like every other commentator he waxes rhetorical himself using the well worn descriptor “medicalization” and suggesting part of the motivation for these changes is pressure from the pharmaceutical industry.  I recently posted a response to a less well written criticism from the Washington Post that addresses these issues and I would encourage anyone interested in finding out what is really going on to take a look at that post.

The question here is what have Professors Foucault and Gutting missed in their critiques about psychiatry?  It turns out they have missed a lot. The first obvious flaw is the misinterpretation about the role of psychiatric diagnosis and a diagnostic manual for psychiatrists.  The DSM (or any technical diagnostic manual) does not represent a blueprint for living and there is no psychiatrist who has ever made that claim.  This error is promulgated in the media by referring to the DSM as a "bible".  In fact, it is not a bible or blueprint for living.  Psychiatrists more than anyone realize that they are addressing a small spectrum of human behavior with the goal of alleviating suffering and restoring function.  The second flaw is that changing a diagnostic criteria in a DSM has any meaning with regard to treatment and diagnosis.  In the case of bereavement that ignores the fact that only a tiny fraction of patients with complicated bereavement or depression ever come to the attention of a psychiatrist.  Grief is a normal human reaction and everybody knows it.  Taken to an absurd level – if organized psychiatry said that everyone with grief needed to take an antidepressant for the simple fact that “we have special knowledge about how people should live”  we would have no credibility at all.  People everywhere know that grief is common and expected and severe mental illnesses are not.  At that level psychiatry is an extension of the common man’s psychology.  The third flaw has to do with impairment.  A diagnosis can be made only with an impairment dimension.  From DSM-IV:

“In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more areas of functioning) or with significantly increased risk of suffering, death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.” – DSM-IV

The critics never acknowledge that like all physicians, a psychiatrist’s role is to treat illness and alleviate suffering.  Further, the clinical method in psychiatry is the only specialty training that emphasizes clinical neutrality and recognizing emotional and intellectual biases that impact the physician patient relationship and offers ways to resolve them.  That is hardly a model for forcing value judgments about preferred mental states on people who other physicians are frequently unable to treat because of their own value judgments.

The author also erroneously concludes that it is dangerous to make psychiatrists “privileged judges of what syndromes should be labeled mental illnesses” based on the fact that “they have no special knowledge about how people should live”.   Since psychiatrists do not make that claim, and since various groups including governments and religious institutions have been making these judgments for centuries with very poor results, I would suggest that psychiatry has had some problems – but the progress here is undeniable.  That makes psychiatrists experts in their own field in their own field and the purveyor of their own diagnostic methods and not a claim that people should live in a particular way.  DSM-IV takes pains to point out that it is classification system for syndromes and NOT people.  The DSM is not designed for an untrained person to look at and make a diagnosis or get guidance for living.  It is designed to be a common language for psychiatrists who have all had standardized training.

I would also like to suggest that the same philosophical criteria be seriously applied by philosophers to the pressing problems within the health care system.  The DSM is not even a gnat on that landscape.  We have had nearly 30 years of active discrimination by governments and insurance companies against persons with mental illness.  While much criticism has been heaped on the bereavement exclusion criteria, people with addictions and serious mental illnesses are routinely denied potentially lifesaving interventions.  This discrimination has been well documented and it has fallen disproportionately on the mentally ill.  Jails and prison have become de facto mental hospitals.  People are being treated with addicting drugs on a large scale to the point that many consider opiate use and deaths from overdose to be an epidemic.  Governments save money and pharmaceutical companies and the managed care cartel prosper.  Contrary to the author’s suggestion that “psychiatrists are more than ready to think that just about everyone needs their services” psychiatrists are rare and access is strictly controlled by managed care companies and the government.  Even if a person sees a psychiatrist, their medications, access to psychotherapy, and access to hospital treatment are all dictated by a business entity rather than their doctor.

It would seem that philosophers could find something to critique in that glaringly bleak health care landscape other than a trivial change in the diagnostic manual of a vanishing medical specialty.   If not, I would be very skeptical  of their arguments.

George Dawson, MD, DFAPA

Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Shorter E.  A History of Psychiatry.  John Wiley & Sons, New York, 1997: 302.   

"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302) 


Addendum:

I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5.  Link.

A Psychiatrist Reads the Washington Post

There are an endless number of ways that the appearance of conflict of interest can be spun to make any organization look bad.  The obvious question is why that always seems to occur with psychiatry?  The arguments all follow the general form that a financial benefit resulting from work related to the pharmaceutical industry disqualifies those experts from writing objective research about medication or rendering opinions about the treatment of psychiatric disorders in general. That is the theme of the latest article from The Washington Post entitled “Antidepressants treat grief? Psychiatry panelists with ties to drug industry say yes."  It is an old story with little variation and I add some commentary based on the organization of the article.

"In what some prominent critics have called a bonanza for drug companies, the American Psychiatric Association this month voted to drop the old wording against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression and thus, treated with antidepressants.”

This statement assumes that this practice is not occurring right now. In fact, it is widely known that the diagnosis of depression is not rigorously made in primary care settings. It is highly likely right now that patients suffering from grief as well as psychological adaptations to acute stress are being treated with antidepressants. There is no reason to believe that the patients being treated in primary care resemble the patients with a diagnosis of major depression in clinical trials of antidepressants.

"The change in the handbook, which could have significant financial implications for the $10 billion  US antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows.”

The previous statement talks about a "bonanza for drug companies" and builds on this image in the second statement. It ignores the fact that most commonly prescribed antidepressants are currently generics and available for as little as four dollars per month. The only two major antidepressants at this time that are not generics are Cymbalta (duloxetine) and Vibryd (vilazodone).  Where does the "10 billion dollar" figure come from?  If you read the entire article on page 5, that figure was from IMS America a company that tracks total prescriptions from American retail pharmacies.  Anyone knowing the applications for antidepressants would know that they are prescribed for many conditions other than depression including headaches, hot flashes, and chronic pain. The total retail sales figure is unlikely to reflect either drug company profits or the amount of depression being treated.

A little arithmetic is always instructive. If we assume that a physician prescribes a generic antidepressant for a patient that costs four dollars per month that translates to a total cost of $48 per year. The $10 billion/year figure quoted here would represent 208 million prescriptions or 66% of the entire population of  the U.S. taking antidepressants 12 months out of the year.  Even if we take $2 billion out of the $10 billion figure for Cymbalta and Vibryd, that results in 53% of the population taking antidepressants 12 months out of the year. Those figures are 5-8 times higher than any actual estimation of antidepressant use.  The $10 billion dollar figure is certainly eye-opening but there is plenty of evidence that it is not remotely accurate and will not have the purported impact on the pharmaceutical industry.

"About 80% of the prescriptions for antidepressants are written by primary-care physicians and others, not psychiatrists, a fact that makes the APA handbook particularly important. Faced with a patient complaining of depression-like symptoms, a general practitioner may be likely to rely on the Association's handbook for advice.”

This statement reveals the authors lack of knowledge about the practice of medicine and about the DSM that he is criticizing. The DSM is strictly a diagnostic manual and it contains no treatment recommendations. Primary care physicians are not avid readers of the DSM and that has probably led to the practice of using a DSM-based checklist – the PHQ-9.  This practice has not been promoted by the APA or the pharmaceutical industry (although the PHQ-9 is copyrighted by Pfizer pharmaceuticals).  Using a checklist to make a rapid diagnoses (in minutes) and rapidly treat large numbers of patients is promoted by managed care organizations and HMOs. That is probably the single greatest factor contributing to antidepressant prescriptions but it is ignored by the author - probably because it challenges his contention that this is all driven by conflict of interest in psychiatry rather than the business world.  It is cheaper for HMOs to treat depression with medications rather than detailed psychiatric assessments and psychotherapy.

"The Association itself runs on a budget of about 50 million a year, and for years industry funding has been critical to its operations. Today, about 14% of the Association's budget comes from pharmaceutical companies, mainly in the form of advertising at annual meetings and publications."

The author does a good job of providing no context here. Is the APA any different from other medical specialty organizations? Does advertising create a conflict of interest? Is any other print media outlet held to that standard? There is information available in those areas.   An Institute of Medicine report focused on conflict of interest showed that the APA's revenue from the pharmaceutical industry was in the middle of the pack with regard to medical specialty societies. As an example, the year that report was done the APA reported that medical companies supplied 28% of their annual income.  The American Academy of Family Physicians reported that 42% of their annual income was from pharmaceutical companies (p 220).  That same report (Recommendation 6.1) noted that increasing work for the pharmaceutical industry correlated with a 7% reduction in real physician wages and recommended that there was nothing wrong with “consulting arrangements based on written contracts for expert services to be paid for at fair market value”.   Depending on the expert involved, restricting the amount to $10,000 per year could practically mean anywhere from 2 to 10 presentations per year or about 2 1/2 weeks of contract work. 

“Other members of the committee have numerous ties to drug companies, too, and not simply conducting research, according to disclosures from last year. One was holding stock in Glaxo Smith Kline, one was a consultant to Servier and another consultant to Pfizer;  one had a grant from AstraZeneca and another a grant from Pfizer and AstraZeneca.”

This is a paragraph from a poorly written section illustrating ties between the 11 member Mood Disorders Work Group set up to draft the guidelines on major depression. There is some explanation of the selection criteria and conflict of interest criteria.  It discusses conflictof interest criteria that the APA designed and made explicit in response to this article.  It provides no context other than an off hand remark by the chairman that he probably regrets making. The article provides no reasonable context for expected reimbursement for experts as consultants to industries or the fact that this is a common practice in many academic departments on any major university campus. In some of those industries, the professional organizations actually make an effort to make sure that businesses are well represented in any process that involves making standards.

"The current handbook-the revised version will be published in the Spring-recommended against diagnosing major depression in the bereaved when the symptoms are milder and of less than two months duration. This is known as the "bereavement exclusion".  (If the signs of depression are severe-the patient has thoughts of suicide, for example-major depression is supposed to be diagnosed)….. The new handbook removes the bereavement exclusion."

There is really nothing new and nothing drastic as anticipated with removing the "bereavement exclusion". To provide a clear example I will quote a text copyrighted in 1982:

"There are many publications that deal with treating psychiatric patients who report recent and remote bereavement. It is possible to find a real or imagined loss in every patient's past. However, for the most part, because there is little evidence from reviewing normal bereavement that there is a strong correlation between bereavement and first entry into psychiatric care, those bereaved who are seen by psychiatrists should be treated for their primary symptoms. This is not to say that the death should not be discussed, but because these people represent a very small subset of all recently bereaved, they should be treated like other patients with similar symptoms but no precipitating cause. A physician seeing a recently bereaved with newly discovered hypertension might delay treatment one or two visits to confirm its continued existence, but treat it if it persists. So the psychiatrist should treat the patient with affective symptoms with somatic therapy but only if the symptoms are major and persist unduly. A careful history of past and present drug and alcohol intake is indicated. Then, the safest and most appropriate drugs to use are the antidepressants. Electroconvulsive therapy is indicated in the suicidal depressed." (Paykel p413-414).

Any psychiatrist worth his or her salt knows the difference between grief and depression and they should know the literature on treating grief, the natural history of grief, and the research on proven non-medical treatment of grief including Interpersonal Psychotherapy (IPT) and grief counseling. When you are seeing a psychiatrist, you are seeing an expert who should know the literature on grief, depression, and the differential diagnosis of depression.  Nothing in this article indicates that.  In fact, quotes are provided to suggest that the APA and psychiatry in general has an interest in redefining “the range of acceptable emotion” rather than using clinical research done by psychiatrists to limit suffering and prevent suicide.

I think the reality here indicates that there is no scandal.  The importance of the DSM-5, the appearance of conflict of interest, and the potential windfall for the pharmaceutical industry appear to be seriously overestimated.  Organized psychiatry is certainly not responsible for what happens  in primary care clinics under the direct guidance of business organizations.  There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment of complicated depressions that may occur during bereavement. The suggestion that medications may be useful in some of these situations and the importance of treating depression in bereavement has been around for at least 30 years.

George Dawson, MD, DFAPA

Peter Whoriskey.  Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes. The Washington Post, December 26, 2012.

Clayton PJ. Bereavement in Handbook of Affective of Disorders.  Eugene S. Paykel (ed). The Guilford Press. New York. 1982  pages 413-414.

APA Reiterates Stringent Rules on Accepting Pharma Support.  Psychiatric News.  Monday December 31,2012.

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/  

 

"Doctors don't label"

In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:

"Doctors don't label...Doctors diagnose, take care of, and treat.  That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it."  William T. Carpenter, MD  - Clinical Psychiatry News September 2012; p 3.

Dr. Carpenter is right and every psychiatrist knows it.  Psychiatrists don't label.  Psychiatrists diagnose.  Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical  contexts.  The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment.  Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists. 

A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association).  Read the letter and draw your own conclusions.  The points of contention listed in the letter have been exposed in several other media contexts.  As I read through the letter there are several problems:

"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."

I don't think that this is an accurate statement.  When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry.   I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic.   Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control  over the treatment of mental illness.  Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak.  Of course any other group of mental health providers is in the same boat. 

"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."

This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders.  The current version states that these conflicts need to be the result of dysfunction within the individual.  It is hard for me to see a situation where this is relevant to the practice of psychiatry.  Is there really a case where I am going to diagnose a person in this situation with a mental disorder?  Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness.  The authors here have focused primarily  on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.  

"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."

The risk of "medicalization" needs to be considered for a moment.  What is "medicalization"?  The implication of this letter at a practical level is that it involves an excessive use of medications.  Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment?  The minority of people taking any kind of psychiatric medication see psychiatrists.  The managed care industry and the government are clearly the driving force.  Current "evidence based" approaches are linked directly to medication use.  A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings.  That approach alone has easily outpaced any DSM5 modifications.  Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible.  You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors.  In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols.  The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.

The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications.  On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems.  Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies.  His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries.  Ignoring psychiatric innovation outside  of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers".  I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.

Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized.  There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists.  There is no group of people better equipped to compensate for these deficiencies.  There is no group of people more aware of the stigma of mental illness and addiction.  Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems.  There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association.  There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.

George Dawson, MD, DFAPA

What replaces DSM5? Whither RDoC?

"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.



With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years.  There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder.  That is where NIMH's Research Domain Criteria (RDoC) come in.

Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment.   For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains.  A very conservative estimate suggests that this alone will take take least one hour of testing.  There will probably need to be a lot of time and effort expended on determining when a person is testable.  An RDoC diagnosis will be both time and resource intensive.  It won't be a template or a checklist.

I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed.  After all,  this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness."  When the RDoC comes to fruition there will not just be one test.  There will be many tests.

Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors.  It is the current political culture that applies junk science to the management of the health care system.  It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country.  The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care.  The care they ration the most is for the treatment of mental illnesses and addictions.

Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology  currently uses to assess heart disease?  The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome.  Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.

You can't implement an RDoC in that environment.

George Dawson, MD, DFAPA

DSM5 Dead on Arrival!

That's right.  The latest sensational blast on the fate of that darling of the media the DSM5 is that it is dead on arrival.  That recent proclamation is from the Neuroskeptic and it is based on the analysis of  criticism of DSM5 criteria for Generalized Anxiety Disorder (GAD).  OK - the original proclamation was "increasingly likely DOA".  I confess that at this point I have not read the original article by Starcevic, Portman, and Beck but the Neuroskeptic provides significant excerpts and analysis.

The broad criticism is that the category has been expanded and is therefore less specific.  The authors are concerned that this will lead to more inclusion and that will have "negative consequences."  The main concern is the "overmedicalization" of the worried and the dilution of clinical trails.  All this gnashing of the teeth leads me to wonder if anyone has actually read the Generalized Anxiety Disorder DSM5 criteria that is available on line.  The proposed new criteria, the old DSM-IV criteria and the rationale for the changes are readily observed.  The basic changes include a reduction on the time criteria for excessive worry from 6 months to three months, the elimination of criteria about not being able to control worry, and the elimination of 4/6 symptoms under criteria C (easy fatigue, difficulty concentrating, irritability and sleep disturbance).  A new section on associated behaviors including avoidance behavior a well known feature of anxiety disorders is included.  The remaining sections on impairment and differential diagnosis are about the same.  The GAD-7 is included as a severity measure although I note that the Pfizer copyright is not included.

So what about all of the criticism?  The "Rationale" tab is a good read on the DSM5 web site.  I can say that clinically non-experts are generally clueless about the DSM-IV features of anxiety especially irritability.  Most psychiatrists have a natural interest in irritability because we tend to see a lot of irritable people.  There has been some isolated work on irritability but it really has not produced much probably because it is another nonspecific symptoms that cuts across multiple categories like the authors apply to cognitive problems and pain.  So I will miss irritability but not much.  Psychiatrists have to deal with it whether we have a category for it or not and hence the need for a diagnostic formulation in addition to a DSM diagnosis (managed care time constraints permitting).

But like most things psychiatric - the worried masses rarely present to psychiatrists for treatment these days.   How likely is it that a busy primary care physician is going to review ANY DSM criteria for GAD?  How likely is it that a person with a substance abuse disorder is going to disclose those details to a primary care physician as a probable cause of their anxiety disorder?  How likely is it that benzodiazepines will be avoided as a first line treatment for any anxiety disorder?  In my experience as an addiction psychiatrist I would place the probability in all three questions to be very low.  It doesn't really matter if you use DSM-IV criteria or DSM5 criteria - the results are the same.

As far as "medicalization" goes, I am sure that somebody (probably on the Huffington Blog) will whip this into another rant about how the DSM5 enables psychiatrists to overdiagnose and overprescribe in our role as stooges for Big Pharma.  But who really has an interest in treating all anxiety like a medical problem?  I have previously posted John Greist's  single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy.  In the meantime, what has the managed care cartel been doing?  Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner.  The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed.  The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment.  Why would the treatment of GAD be any different?

It should be obvious at this point that I am not too concerned about the DSM5, DSM-IV, or whatever diagnostic system somebody wants to use.  The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section.  Like many my speculation is that the ultimate information based approach to psychiatric disorders rests in genomics and refined epigenetic analysis and I look forward to that information being incorporated at some point along the way.

But let's get realistic about why the results of DSM technology are limited.  As it is with DSM-IV and as it will be with DSM5, clinicians are free to interpret and diagnose basically whatever they want.  Even with the vagaries of a DSM diagnosis, I doubt that the majority of primary care treatment hinges on a DSM diagnosis of any sort.  I also doubt that the dominant managed care approach to diagnosis and treatment of GAD depends on a psychiatric diagnosis or research based treatment.  It certainly excludes psychotherapy.  Trying to pin those serious deficiencies as well as overexposure to medication on the DSM and psychiatrists is folly.

George Dawson, MD, DFAPA


1: Gorman JM. Generalized anxiety disorders. Mod Probl Pharmacopsychiatry. 1987; 22: 127-40. PubMed PMID: 3299062.

A Positive Review of DSM5? In the New York Times?

I know it is hard to believe.  Something about psychiatry in the NY Times that is not spun as negatively as possible.  One blogger referred to the phenomenon as "New York Times Psychiatry".  But today there is a positive review of the addiction section of DSM5.  No spin on how the DSM is a carefully crafted plot by psychiatry to diagnose all Americans with a mental illness or collude with Big Pharma to sell more drugs.  Instead an author suggesting that there may be a scientific basis for these decisions.  And as we all know, science is a process and not a set of definitive answers.  Could science actually be the organizing force in the DSM rather than what we typically hear in the media?

Probably.

This is a brief scholarly essay on the history of the concept of addiction and the current neurobiological underpinnings.   It should be no surprise that with the accumulation of knowledge that the concepts of what is an addiction and what is not changes over time.  Just like everything else in the DSM and just like everything else in the field of medicine.  It is not a conspiracy or a plot - it naturally happens as knowledge accumulates and we get more sophisticated.

George Dawson, MD, DFAPA


Howard Markel.  DSM 5 Gets Addiction Right.  NY Times June 5, 2012.

Myths in the Huffington Post

Let me start out by saying that I have a low opinion of the Huffington Post largely because of its rhetorical approach to psychiatry.  Tales about the pharmaceutical company corruption of psychiatry, ongoing articles about the myth of mental illness, references to very poorly done research that supposedly discredits psychiatry, the idea that the DSM is either a manual for everyman instead of clinical psychiatrists or a book written to manipulate the general public - the Huffington Post has it all and then some.  Interestingly, the Huffington Post lists these postings under "Science" when it is clear that nobody there seems to know the first thing about science or how it differs from personal opinion.  From what I have seen, listing yourself as an authority on science apparently makes it so on the Internet.  "Rhetoric/Politics" would be a much more accurate heading.

Enter Allen Frances commenting in blog form.  I have already responded to one of the Dr. Frances editorials that seem to pop up everywhere.  I find the whole process of taking a scientific debate within a professional society into a public forum somewhat appalling.  In this case, the rhetorical device of applying a decision made about an entirely different process - withdrawing a paper that the author believes was incorrectly done due to a methodological error ( one that is common to much psychosocial research) to the DSM process seems rhetorical to me.  That occurs after the process has been thoroughly politicized in the media.

The arguments themselves are either red herring or they make it seem like the very public decrying of the DSM process has shamed the APA into not declaring grief and psychosis risk to be diagnoses.  The public will never know what the APA process would have decided on these issues and of course every critic wants to take credit for exposing the APA as a group of money grubbing scoundrels whose only mission in life is to appease Big Pharma or generate huge revenue for the organization.

I wish I could count on the public to be as skeptical of these opinions as they are of other political opinions.  Unfortunately after 25 years of practice, I can say with certainty that only a few people know what a psychiatrist is or how they are trained.  Today there is more misinformation than ever about psychiatry via the Internet.

As a reminder, the DSM is for clinical psychiatrists and psychiatric research.  Reading criteria without the associated training is not the same thing as making a diagnosis.  There are many nonpsychiatric mental health professionals and many nonpsychiatric physicians.  In fact, the bulk of psychotropic medications in this country are prescribed by nonpsychiatric physicians.  Access to psychiatrists is tightly controlled by managed care companies and state governments. It is difficult to see a psychiatrist initially and over time.  These same managed care organizations control who is admitted to and discharged from inpatient psychiatric units and the type of care provided there.

The idea that the APA is an omnipotent organization with the power to manipulate and control the provision of mental health care through out the USA is a myth of massive proportions.  The idea that the DSM is a potential tool for that manipulation is another.

You can probably read about that first on the Huffington Post.

George Dawson, MD, DFAPA