A Grand DSM critique from Health Affairs

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)

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.

George L. Engel, MD. JAMA.2000;283(21):2857. doi:10.1001/jama.283.21.2857