DSM-5: Psychiatry's Contested Bible - Page 3

By Michael Dhar 04/05/13

The new 1,000-page psychiatrists' Big Book will redefine addiction. Critics are already demanding a boycott. The Fix guides you through the highlights.

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How are Big Pharma dollars mixed up in this?

Diagnosis inflation is a bonanza for Big Pharma, which already makes hundreds of millions of dollars from the 20% of Americans who are prescribed psychoactive drugs. Many addicts with dual diagnoses already take these medications. With many substance users now likely to seek treatment earlier, clinicians will be incentivized to diagnose depression, anxiety or another common mental problem alongside the addiction, and then send patients to psychiatrists who can prescribe drugs. In addition, the proliferation of new medical conditions in the DSM-5 gives drug makers the opportunity to market the same drugs for new indications. 

“Drug companies will laugh all the way to the bank,” Frances wrote in a letter to The New York Times last month.

The ties among psychiatrists and drug companies are longstanding and deep. When it comes to taking money from Big Pharma, psychiatry consistently leads the pack of all medical specialties. Links to pharma among DSM-5 members have increased—rising by 20% since the book's previous edition, according to a study by Lisa Cosgrove, PhD, associate professor of clinical psychology at the University of Massachusetts-Boston, and Sheldon Krimsky, PhD, a professor of urban and environmental policy and planning at Tufts University.

That increase occurred despite a move by the APA to require that all DSM committee members disclose their industry ties. The findings show that “simply disclosing the conflict is not enough,” Krimsky tells The Fix. 

In its response, the APA noted that 72% of DSM-5's members reported no ties to pharma last year. (However, that may mean the members cut ties only in 2012, the study notes.)

The medicalization of mental illness and addiction is not new. It began in the late ‘70s, and the DSM played a critical role. According to Marcia Angell, MD, the former editor of the New England Journal of Medicine, financial self-interest drove psychiatry’s redefinition of psychological problems as medical conditions. At the time, more and more psychologists and social workers were functioning as therapists, and psychiatrists moved to take back the field by playing their trump card: As medical doctors, they had the legal authority to write prescriptions. And diseases demand medicine.

The revision of the DSM led this realignment. In an aggressive media campaign, the APA announced that the new DSM-III would “remedicalize psychiatry” and offer “a defense of the medical model as applied to psychiatric problems,” Angell said. The official reason for the sweeping overhaul? Keeping up with the science. Sound familiar?

That practical skepticism, combined with the unprecedented criticism, may signal a slow erosion in the DSM's Biblical status. 

“By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions,” Angell wrote in the New York Review of Books in 2011. “Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.”

 How much does the DSM-5 matter, anyway?

For some, the controversies surrounding the new manual have a simple solution: “I would tell people not to use it,” says Kinderman.

Other critics take a more balanced perspective, advising patients and practitioners simply to recognize that the DSM is not the sole authority for addiction diagnosis or treatment. Cosgrove advises patients and providers to investigate alternative guidelines, such as those developed by the British National Institute for Clinical Excellence (NICE), which incorporate perspectives beyond psychiatry. 

Calls to end monopolies, particularly on topics as important and sensitive as psychiatric diagnoses, may sound eminently reasonable. But the practical realities of treatment also make such boycott efforts mostly symbolic, says psychologist Richard Juman, PhD, who formerly headed the New York State Psychological Association (and now coordinates The Fix's Professional Voices section)

So, for the foreseeable future, the DSM-5 is likely to remain psychiatry's Bible, if only because of the tyranny of insurance paperwork: Therapists, for example, need to provide a patient's DSM diagnosis on the bill in order to get paid. But while critics say the DSM-5 fails to recognize the complexity of individual patients, the pile-on of condemnation may underestimate the complexity of treatment providers: That is, clinicians already know that the DSM is an imperfect manual, and even as they use it institutionally to meet insurance requirements and as a symptom reference, they know to take each individual case as it comes. “There is nothing so radical in DSM-5 that clinicians will be unable to come up with an accurate diagnosis,” says Juman.

Clinicians will continue to take the DSM with a grain of salt, agrees Alexis Edwards, PhD, an assistant professor at the Virginia Institute of Psychiatric and Behavioral Genetics, whose own research identified some shortcomings in the new book's alcoholism diagnoses. "I have a lot of faith in clinicians that if they identify someone as having a problem, they'll find a way to help them," she says. "Guidelines are important, but they don't always have the right answer."

That practical skepticism, combined with the unprecedented criticism leveled at the DSM's fifth incarnation—and at psychiatry's increasing propensity to medicate patients—may signal a slow erosion of the publication's status. Ironically, critics calling for the DSM's abolition may grant it as much perceived authority as the proponents who want to make the manual scientifically precise. But in the hospitals and clinics where addiction and other forms of psychiatric suffering actually get treated, the guide is just a book—not a Bible. And its sway may be diminishing, even as the tome itself adds more and more pages and diagnoses.

Michael Dhar is a medical and science writer who has written for Livescience.com, Science & Medicine, Iowa Outdoors and various medical and research institutions. This is his first piece for The Fix.

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