[Commentary] [USA] Diagnosing the D.S.M.

[Stephanie Stevens]

New York Times, NY, USA


OP-ED CONTRIBUTOR

Diagnosing the D.S.M.

By ALLEN FRANCES

Published: May 11, 2012


AT its annual meeting this week, the American Psychiatric Association
<http://www.psychiatry.org/> did two wonderful things: it rejected one
reckless proposal that would have exposed nonpsychotic children to
unnecessary and dangerous antipsychotic medication and another that
would have turned the existential worries and sadness of everyday life
into an alleged mental disorder.

But the association is still proceeding with other suggestions
<http://www.medpagetoday.com/MeetingCoverage/APA/32619> that could
potentially expand the boundaries of psychiatry to define as mentally
ill tens of millions of people now considered normal. The proposals
are part of a major undertaking: revisions to what is often called the
“bible of psychiatry” — the Diagnostic and Statistical Manual of
Mental Disorders <http://www.psychiatry.org/practice/dsm> , or D.S.M.
The fifth edition <http://www.dsm5.org/Pages/Default.aspx> of the
manual is scheduled for publication next May.

I was heavily involved in the third and fourth editions of the manual
but have reluctantly concluded that the association should lose its
nearly century-old monopoly on defining mental illness. Times have
changed, the role of psychiatric diagnosis has changed, and the
association has changed. It is no longer capable of being sole
fiduciary of a task that has become so consequential to public health
and public policy.

Psychiatric diagnosis was a professional embarrassment and cultural
backwater until D.S.M.-3 was published in 1980. Before that, it was
heavily influenced by psychoanalysis, psychiatrists could rarely agree
on diagnoses and nobody much cared anyway.

D.S.M.-3 stirred great professional and public excitement by providing
specific criteria for each disorder. Having everyone work from the
same playbook facilitated treatment planning and revolutionized
research in psychiatry and neuroscience.

Surprisingly, D.S.M.-3 also caught on with the general public and
became a runaway best seller, with more than a million copies sold,
many more than were needed for professional use. Psychiatric diagnosis
crossed over from the consulting room to the cocktail party. People
who previously chatted about the meaning of their latest dreams began
to ponder where they best fit among D.S.M.’s intriguing categories.

The fourth edition of the manual, released in 1994, tried to contain
the diagnostic inflation that followed earlier editions. It succeeded
on the adult side, but failed to anticipate or control the faddish
over-diagnosis of autism, attention deficit disorders and bipolar
disorder in children that has since occurred.

Indeed, the D.S.M. is the victim of its own success and is accorded
the authority of a bible in areas well beyond its competence. It has
become the arbiter of who is ill and who is not — and often the
primary determinant of treatment decisions, insurance eligibility,
disability payments and who gets special school services. D.S.M.
drives the direction of research and the approval of new drugs. It is
widely used (and misused) in the courts.

Until now, the American Psychiatric Association seemed the entity best
equipped to monitor the diagnostic system. Unfortunately, this is no
longer true. D.S.M.-5 promises to be a disaster — even after the
changes approved this week, it will introduce many new and unproven
diagnoses that will medicalize normality and result in a glut of
unnecessary and harmful drug prescription. The association has been
largely deaf to the widespread criticism of D.S.M.-5, stubbornly
refusing to subject the proposals to independent scientific review.

Many critics assume unfairly that D.S.M.-5 is shilling for drug
companies. This is not true. The mistakes are rather the result of an
intellectual conflict of interest; experts always overvalue their pet
area and want to expand its purview, until the point that everyday
problems come to be mislabeled as mental disorders. Arrogance,
secretiveness, passive governance and administrative disorganization
have also played a role.

New diagnoses in psychiatry can be far more dangerous than new drugs.
We need some equivalent of the Food and Drug Administration to mind
the store and control diagnostic exuberance. No existing organization
is ready to replace the American Psychiatric Association. The most
obvious candidate, the National Institute of Mental Health
<http://www.nimh.nih.gov/index.shtml> , is too research-oriented and
insensitive to the vicissitudes of clinical practice. A new structure
will be needed, probably best placed under the auspices of the
Department of Health and Human Services, the Institute of Medicine or
the World Health Organization.

All mental-health disciplines need representation — not just
psychiatrists but also psychologists, counselors, social workers and
nurses. The broader consequences of changes should be vetted by
epidemiologists, health economists and public-policy and forensic
experts. Primary care doctors prescribe the majority of psychotropic
medication, often carelessly, and need to contribute to the diagnostic
system if they are to use it correctly. Consumers should play an
important role in the review process, and field testing should occur
in real life settings, not just academic centers.

Psychiatric diagnosis is simply too important to be left exclusively
in the hands of psychiatrists. They will always be an essential part
of the mix but should no longer be permitted to call all the shots.

--

Allen Frances, a former chairman of the psychiatry department at Duke
University School of Medicine, led the task force that produced
D.S.M.-4.


© 2012 The New York Times Company

http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html