Sunday, April 29, 2012

Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine | candidaabrahamson

Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine | candidaabrahamson

Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine

Posted on April 13, 2012by
In the interest of full disclosure, let me be perfectly clear.
As a therapist, I use the DSM (Diagnostic and Statistical Manual of Mental Disorders), the ‘mental health bible’ that helps diagnose and define treatment, frequently. I find it pivotal in making diagnoses, and then in providing a shared language to discuss those diagnoses with consulting psychiatrists, with other treaters, with educators. I share it with clients to assist them in understanding their illnesses and potential treatments, and it’s a useful tool to help third-party payers understand the needs of the patients.
Really, overall I’m a fan, and I rely upon it.
Which is probably why I find myself so frustrated with the current process of updating the (ready for this one?) DSM-IV-TR (don’t ask) to the DSM-5.
Perhaps I’m an innocent (highly unlikely), but I had counted on the American Psychiatric Association (APA), the group responsible for the updating of the DSM (soon this will be an alphabet soup), to keep the process relatively untainted.
I had counted wrong.


Again in the interest of full disclosure, I had already found myself frustrated with several of the committee on the DSM-5‘s decisions. In an act of tremendous restraint, I won’t go over again my opposition to doing away with the bereavement exclusion [but won't deprive you of a hyperlink to my mini-rant], nor will I carry on again about the potential inclusion of Hypersexuality and Internet Addiction [ok--link here if you can't keep yourself away]. But the APA’s process of updating ‘the mental health bible’ crawled under my skin once again–not for its lack of full disclosure, really, as much as its seeming indifference to what the disclosure indicated.
Just for some background: There are 141 panel members on the 13 DSM-5 panels and 29 task force members. The members of these 13 panels are the ones in charge of revisions to diagnostic categories and inclusion of new disorders.
So far, so good.
Until you look a bit further, and realize the DSM-5 process has enough ties to big money (pharmaceutical money, of course), to make good old Bernie Madoff, who, it turns out, had very few ties to actual money, squirm with jealousy.
In “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists,” Lisa Cosgrove, PhD, from the Edmond J. Safra Center for Ethics at Harvard University, and Sheldon Krimsky, PhD, from the Department of Public Health and Community Medicine at Tufts University, write the following astonishing facts about the DSM’s financial connections to big pharm:
Three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry. It is also noteworthy that, as with the DSM-IV, the most conflicted panels are those for which pharmacological treatment is the first-line intervention. For example, 67% . . . of the panel for Mood Disorders, 83% . . . of the panel for Psychotic Disorders, and 100% . . .[Note to reader: this 100% is a personal favorite of mine. How can you beat it?] of the Sleep/Wake Disorders (which now includes “Restless Leg Syndrome”) have ties to the pharmaceutical companies that manufacture the medications used to treat these disorders or to companies that service the pharmaceutical industry.


So if I’ve got this right [and I have a good sense that I do; it isn't as difficult as the proverbial rocket science], and if I return for the moment to the DSM-5′s exclusion of the bereavement clause, which means, just to sum up, that after two weeks of grief symptoms (which, it is already known and accepted, overlap with depressive symptoms), a bereaved person can be diagnosed with depression, I could be looking at something like this, if I were take the most Machiavellian view. Depression, as opposed to grief, can be treated with and has found to be responsive to psychotropic medications. Thus turning grief into a depression yields more prescriptions, which could potentially benefit any of that high percentage of doctors sitting on the committee with connections to the companies that make these meds.
I don’t really think that the 67% of the Mood Disorders committee members insisted on turning grief into a mood disorder with the thought that they would profit financially, hoping that the pharmaceutical companies they’re connected would step in to provide psychotropics to the bereaved. Not for a moment. But it might be difficult for those committee members to completely keep that idea out of their heads. That’s why conflicts of interests are problems.
Krimsky himself clarified that his article was not meant to be a ‘witch hunt.’ He said, “I don’t believe that anyone on the panel is purposefully making decisions that favor industry. The issue is more subtle and just as impactful. We all have the potential for bias in a conflicted situation, and we’re all really defended against looking at those biases, and therein lies the danger.”
I enjoyed some of the APA’s responses to the Krimsky-Cosgrove article. Take David Elkins, president of the American Psychological Association’s Society for Humanistic Psychology (a society I, myself, had never heard of until the other day, but one with a title that piques my interest. And–who knew?–it’s division #32 of the American Psychological Association. I think my time could be well spent finding what the first 31 divisions are.).
When asked what he had to say in response to the fact that seven in 10 DSM-5 task force members have drug company ties, Elkins was eloquent.
He was, not to put too fine a point on it, “dismayed.”
I love a man of few words.
But it gets better. The APA medical director and CEO is one Dr. James Scully. And he says–and I don’t want people to miss this:
We wanted to include a wide variety of scientists and researchers with a range of expertise and viewpoints in the DSM-5 process. Excluding everyone with direct or indirect funding from the industry would unreasonably limit the participation of leading mental health experts in the DSM-5 development process.
Ok, I admit it. Those are my own italics. I can’t help it; it’s priceless.
So, according to Scully, it’s worse than we even thought. Looking for a mental health expert? Just know she’s connected to the pharmaceutical companies. So much so, that if you keep anyone connected to the drug makers out of a given process, you’ve lost your expertise base.
Now I feel better about the whole thing.
And the truth is that this isn’t as much of a shock to me as it might have been. One incident proves little, but it made an impression on me, and, woven into the tapestry of the Scully argument, bolsters my concern about the infiltration of the drug companies into clinical practice.
The consulting psychiatrist and I met together with a patient to get all views on the table at once, and to present a cohesive treatment plan. We met in the psychiatrist’s office, where the doctor kindly proffered me a pen as I searched my purse for one I couldn’t find [of course, now that I didn't need them, I could locate my glasses, my bottle of baby aspirin, and the receipt for the panty hose I'd been meaning to return--but couldn't find the receipt].
This was no plain pen–it was a Paxil pen–with the medicine’s name and logo written large upon it. The pad of paper he provided was dominated by Effexor’s name–and, I kid you not, he had a Seroquel mug. My patient and I sanitized our hands from a plastic bottle emblazoned with ‘Pristiq,’ and I actually watched time pass on a cheap plastic clock with Abilify’s name plastered across the face.
I stayed put, for I was certain, had I gone to the restroom, I would have been met with toilet paper carrying Zyprexa’s name, and that, really, was the limit.



And here’s the thing: This office isn’t unusual in its collection of tchotchkes advertising psychotropics or other meds. It’s all over.
In the interest of full disclosure, let me clarify: I thought this was an excellent psychiatrist. Probably he’s sitting on the Mood Disorders committee of the DSM-5, offering his expert opinion, and writing down notes on his Zoloft clipboard.
Because if you cut him out of the DSM-5 process just because he’s connected to the pharmaceutical companies–really, who do you have left?
You know what? In the interest of full disclosure I tell you: I’ve never heard of the APA’s society for humanistic psychology, but I’m right there with its president. When it comes to how the DSM-5 is being compiled, I too am–in a word–”dismayed.”
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13 Responses to Money Motivates Mental Health Moves: DSM-5, Meet Makers of Medicine

  1. Pingback: Money Motivates Mental Health Moves: DSM-5, Meet Makers of …
  2. janenemurphy says:
    April 13, 2012 at 7:19 pm
    Dismayed, indeed. What an alarming post. The big question is, what can we do?
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  3. psachno says:
    April 14, 2012 at 4:49 pm
    Your posts are so educational! Thanks for all this info–AND for your references.
    Can I sign a petition if I am unlicensed? (Probably not, hey?)
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  4. Paul says:
    April 14, 2012 at 8:59 pm
    Very good, informative article. I don’t think the bereavement exemption issue is as one-sided as you present it, however. By removing that exemption, it doesn’t cause all mourners to gain the diagnosis of depression. What it does is *allow* the diagnosis of depression. While it would be silly to say that everyone who suffers from the symptoms of depression for several weeks after a loved one has died is clinically depressed, it would be equally silly to say that it is impossible for someone who had a loved one die to become depressed. Removing the exemption allows help-seeking individuals who are indeed suffering from a depressive episode triggered by the death of a loved one to get help. Right now, that group of people don’t qualify for the diagnosis, and therefore might not be able to get insurance reimbursement for help.
    I had the worse deppresive episode of my life for about 6 months after my cat died. Luckily for me, my diagnosis is type-II bipolar which doesn’t have a (pet) bereavement exclusion clause, b/c I was suffering terribly and I was able to recover with the combination of medicine and therapy. I’m not saying that there aren’t potential negative consequences of removing the bereavement exemption, but I really don’t think you should lump it in with the negative consequences of undue involvement by the industry in the revision process.
    If nothing else, removing the exemption, along with some other things like changing from a more categorical to dimensional approach, represents a change in the dsm-III/iv philosophy of mental disorders being discrete disease entities with an implied fully biological etiology. I’m not saying this will hamper the industry or slow down the monetezation of mental illness, but it is an interesting trend worth watching.

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Psychiatry’s bible, the DSM, is doing more harm than good - The Washington Post

Psychiatry’s bible, the DSM, is doing more harm than good - The Washington Post

Psychiatry’s bible, the DSM, is doing more harm than good


By Paula J. Caplan, Published: April 27


About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Since the 1980s, when I first made public my concerns about psychiatric diagnosis, I have heard from hundreds of people who have been arbitrarily slapped with a psychiatric label and are struggling because of it. About half of all Americans get a psychiatric diagnosis in their lifetimes. Receiving any of the 374 psychiatric labels — from nicotine dependence disorder to schizophrenia — can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions. In light of the subjectivity of these diagnoses and the harm they can cause, we should be extremely skeptical of them.

Psychiatric diagnosis is unregulated, so the doctor who met briefly with the aforementioned patient wasn’t required to spend much time understanding what caused her heart to race or to seek another doctor’s opinion. If he had, the patient would have realized that her bipolar diagnosis wasn’t necessary or appropriate. Neither on her ER trip nor in later visits to therapists did anyone explain how sleep deprivation impairs the body’s ability to handle pressure.

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.

According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.

When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Over the next 10 months, the woman lost her friends, who attributed her normal mood changes to her alleged disorder. Her self-confidence plummeted; her marriage fell apart. She moved halfway across the country to find a place where, on her dwindling savings, she and her son could afford to live. But she was isolated and unhappy. Because of the drug she took for only six weeks, she now, more than three years later, has an eye condition that could destroy her vision.

This patient is well-educated and white, and before her illness, she was wealthy. Research reflects that she was more likely to be diagnosed as mentally ill than a man in her circumstances. Racism, classism, ageism and homophobia can also affect who receives a psychiatric diagnosis.

It would be less troubling if such diagnoses helped patients, but getting a label often hinders recovery. It can lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering.

The marketing of the DSM has been so effective that few people — even therapists — realize that psychiatrists rarely agree about how to label the same patient. As a clinical and research psychologist who served on (and resigned from) two committees that wrote the current edition of the DSM, I used to believe that the manual was scientific and that it helped patients and therapists. But after seeing its editors using poor-quality studies to support categories they wanted to include and ignoring or distorting high-quality research, I now believe that the DSM should be thrown out.

An undeserved aura of scientific precision surrounds the manual: It has “statistical” in its title and includes a precise-seeming three- to five-digit codefor every diagnostic category and subcategory, as well as lists of symptoms a patient must have to receive a diagnosis. But what it does is simply connect certain dots, or symptoms — such as sadness, fear or insomnia — to construct diagnostic categories that lack scientific grounding. Many therapists see patients through the DSM prism, trying to shoehorn a human being into a category.

At a convention in Philadelphia starting May 5, the DSM’s publisher, the American Psychiatric Association, is due to vote on whether to send the manual’s next edition, the DSM-5, to press. The APA is a lobbying group for its members, not an organization with patients’ interests as its top priority. It has earned $100 million from sales of the current edition, the DSM-IV.

Allen Frances, lead editor of the current DSM, defends his manual as grounded in science, but at times he has acknowledged its lack of scientific rigor and the overdiagnosing that has followed. “Our net was cast too wide,” Frances wrote in a 2010 Los Angeles Times op-ed, referring to the explosion of diagnoses that led to “false ‘epidemics’ ” of attention deficit disorder, autism and childhood bipolar disorder. The current manual, released in 1994, he wrote, “captured many ‘patients’ who might have been far better off never entering the mental health system.”

Frances has even said that “there is no definition of a mental disorder. . . . These concepts are virtually impossible to define precisely.”

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.

Patients should not be limited in their choices of treatment, but they should be better informed. If someone knows about the many ways that suffering can be addressed, including a drug or a treatment with potential benefits and harms, and they still want to try it, they should be able to.

While patients who think they have been harmed by a diagnosis can file a lawsuit or a complaint with a state licensing body, that almost never happens. However, this weekend marks a big change, as some people are speaking up: About 10 people who received diagnoses from the current DSM edition are filing complaints against the manual’s editors. (I have worked with the patients to prepare their complaints, and I’m filing my own as a concerned clinician.)

The complainants allege that the DSM’s editors failed to follow the APA’s ethical principles, which include taking account of scientific knowledge and respecting patients’ welfare and dignity. They are asking the APA to order the editors to redress the harm done to them — or in one case, to a deceased relative — and to anyone else hurt by receiving a label. They want the APA to hold a public hearing about the dangers of psychiatric diagnosis to gather information about the extent of the damage and look for ways to minimize it. Additionally, they are asking the APA to make clear to therapists and to the public that psychiatric diagnoses are not scientific and that they often put patients at risk.

As the patient labeled as bipolar told me: “If I had never been diagnosed, I probably would still be married, would live close to family and friends and not be so lonely, and would not be living on the financial edge.”

outlook@washpost.com

Paula J. Caplan, a clinical and research psychologist, is a fellow in the Women in Public Policy Program at Harvard’s Kennedy School of Government. She is the author of “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.”

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