I read the article by Dr Frances and was impressed by its intelligence. I then read the response by the APA in the person of Dr Schatzberg et al. I was shocked by its sleazy attack on Dr Frances’ integrity. Dr Frances was accused of arguing because of anticipated personal financial gain. The accusation that Dr Frances was arguing ad hominem was the pot calling the kettle black.
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.
Arnold Knepfer, MD
Read more!
Thursday, September 17, 2009
Wednesday, September 16, 2009
Toward mental illness for all?
We were surprised to read of the open letter by Drs Frances and Spitzer regarding the creation of DSM-V. Over time we have been puzzled by a succession of Diagnostic and Statistical Manuals, and have been forced to conclude the long-term purpose of the DSM is to abolish mental illness from American society. Currently only half of all Americans fit the criteria in DSM-IV to be diagnosed with one kind of mental illness or another. 1 Surely the goal of DSM-V must be to increase the percentage of Americans eligible to be mentally ill. With the inclusion of sub-syndromal categories in DSM-V, the total percentage of mentally ill Americans should reach 75-80%. With a long-term commitment by the American Psychiatric Association to DSM-VI --or, if necessary, DSM-VII - - 100% of the American population can eventually be declared mentally ill. On that glorious day all mental health practitioners can take satisfaction in their decades long quest to abolish mental illness, because, as we all know, when everyone has something then no one has it.
1.“Mental Illness in U.S. Presidents Between 1776 and 1974,” J. R. T. Davidson, K. M. Connor, and M. Swartz, The Journal of Nervous and Mental Disease. Read more!
1.“Mental Illness in U.S. Presidents Between 1776 and 1974,” J. R. T. Davidson, K. M. Connor, and M. Swartz, The Journal of Nervous and Mental Disease. Read more!
Thursday, September 3, 2009
This Accusation Has No Logic. . .
The APA DSM-V Task Force’s response to Dr. Frances’s critique of DSM-V noted that his royalties for DSM-IV products would cease when DSM-V is published. However, Dr. Frances’ critique called for DSM-V developers to make fewer changes- - not more, and he made no call for longer DSM-V field trials; in fact he proposed additions such as prodromal and subthreshold syndromes to be put in an appendix that called for further research. His critique then would not extend his receipt of royalties, and perhaps even shorten them. Thus, the APA has no logic to accuse him of financial incentive unless they opine that his critique could significantly delay publication of DSM-V somehow, eg, by inciting turmoil within the working group which would mean that a critical mass of people would agree with his logic.
Doug Berger, M.D., Ph.D.
U.S. Board-Certified Psychiatrist
Tokyo, Japan Read more!
Doug Berger, M.D., Ph.D.
U.S. Board-Certified Psychiatrist
Tokyo, Japan Read more!
Preserving Irrelevance?
I agree with Drs Schatzberg, Scully, Kupfer and Regier. In my busy clinical practice, I do not see DSM-IV doing justice to clinical reality. Less than 25% of my patients have a genuinely good syndromatic fit with specific DSM diagnoses.
With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.
DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.
While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.
Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.
Prevesh Rustagi, MD Read more!
With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.
DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.
While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.
Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.
Prevesh Rustagi, MD Read more!
Wednesday, September 2, 2009
Members of the International Public Are Also Disappearing into a DSM Black Hole
In response to Dr. Johnson’s post, “Like Writing a Letter to Santa Claus,” UK Patient Advocate Suzy Chapman notes that Web-based platforms like Wiki and Facebook are likely to be viewed as little more than token nods in the direction of transparency and stakeholder participation.
[Note: Comment slightly edited from original.]
In June of this year, I raised inquiries with the DSM-V Task Force in relation to the APA’s participation in the World Health Organization’s (WHO) International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders which were passed on to the APA’s Media Relations office.
I was first quizzed on whether I was a member of the press and then whether, as a patient advocate, I was working on behalf of a specific organization. I was told that before the APA was to provide answers to my inquiries, I was to disclose my plans for this information and whether I intended to publish responses. The basis on which these inquiries were being made was duly supplied to the APA’s Media Relations office.
Six weeks down the line, no answers have been forthcoming. Following several gentle prods for a response, I was told that the APA’s Media Relations office “had responded to [my] many other inquiries” and that “the information is available on the DSM-V Web site.”
Since not one query has been answered, since the information requested is not available on the APA’s DSM-V Web site, and since APA’s Media Relations office has declined my request to resend any response they may have already issued, one can only conclude that the APA is seeking to obfuscate the issue.
Similarly, the WHO has embraced new platforms such as wikis and Facebook as part of its own revision process towards ICD-11, in order to facilitate communication and participation by professionals, users, and stakeholders in the ICD-11 development process. But plain, old-fashioned written inquiries relating to the lack of meeting summaries; the provision of a list of members of the ICD-DSM Harmonization Group (which isn’t apparent from the WHO’s Web site), and clarification of what is (or will be) the channel of communication for interest groups wishing to communicate with, or submit proposals to, the new TAG (Topic Advisory Group) for Neurology are being ping-ponged between various key WHO steering and advisory group members. Again, no answers are forthcoming, and there appears to be some difficulty in identifying who is mandated to address such inquiries.
In September 2008, former DSM Work Group Chair Robert L. Spitzer, MD compared the “transparency” of the WHO with that of the current DSM revision Task Force: “It should be noted that in contrast to this new APA confidentiality policy, which discourages DSM-V members from providing information about the ongoing revision process, the World Health Organization has adopted the opposite policy with regard to its development of ICD-11. Minutes of all ICD-11 meetings are posted on the WHO website without any restrictions on who can have access...”
In practice, the WHO would not appear to be publishing minutes of all its meetings on the WHO website other than summary reports of the first 3 meetings of the Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. Coordinator Dr Geoffrey Reed has yet to publish a summary of the Advisory Group’s last meeting held in Geneva 9 months ago. So I would question Dr Spitzer’s view.
Inquiries from members of the public are also disappearing into a DSM black hole.
Suzy Chapman
UK Patient Advocate Read more!
[Note: Comment slightly edited from original.]
In June of this year, I raised inquiries with the DSM-V Task Force in relation to the APA’s participation in the World Health Organization’s (WHO) International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders which were passed on to the APA’s Media Relations office.
I was first quizzed on whether I was a member of the press and then whether, as a patient advocate, I was working on behalf of a specific organization. I was told that before the APA was to provide answers to my inquiries, I was to disclose my plans for this information and whether I intended to publish responses. The basis on which these inquiries were being made was duly supplied to the APA’s Media Relations office.
Six weeks down the line, no answers have been forthcoming. Following several gentle prods for a response, I was told that the APA’s Media Relations office “had responded to [my] many other inquiries” and that “the information is available on the DSM-V Web site.”
Since not one query has been answered, since the information requested is not available on the APA’s DSM-V Web site, and since APA’s Media Relations office has declined my request to resend any response they may have already issued, one can only conclude that the APA is seeking to obfuscate the issue.
Similarly, the WHO has embraced new platforms such as wikis and Facebook as part of its own revision process towards ICD-11, in order to facilitate communication and participation by professionals, users, and stakeholders in the ICD-11 development process. But plain, old-fashioned written inquiries relating to the lack of meeting summaries; the provision of a list of members of the ICD-DSM Harmonization Group (which isn’t apparent from the WHO’s Web site), and clarification of what is (or will be) the channel of communication for interest groups wishing to communicate with, or submit proposals to, the new TAG (Topic Advisory Group) for Neurology are being ping-ponged between various key WHO steering and advisory group members. Again, no answers are forthcoming, and there appears to be some difficulty in identifying who is mandated to address such inquiries.
In September 2008, former DSM Work Group Chair Robert L. Spitzer, MD compared the “transparency” of the WHO with that of the current DSM revision Task Force: “It should be noted that in contrast to this new APA confidentiality policy, which discourages DSM-V members from providing information about the ongoing revision process, the World Health Organization has adopted the opposite policy with regard to its development of ICD-11. Minutes of all ICD-11 meetings are posted on the WHO website without any restrictions on who can have access...”
In practice, the WHO would not appear to be publishing minutes of all its meetings on the WHO website other than summary reports of the first 3 meetings of the Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. Coordinator Dr Geoffrey Reed has yet to publish a summary of the Advisory Group’s last meeting held in Geneva 9 months ago. So I would question Dr Spitzer’s view.
Inquiries from members of the public are also disappearing into a DSM black hole.
Suzy Chapman
UK Patient Advocate Read more!
Tuesday, September 1, 2009
On Integrity and Never Ending Diagnostic Updates…
I read the article by Dr Frances and was impressed by its intelligence. I then read the response by the APA in the person of Dr Schatzberg et al. I was shocked by its sleazy attack on Dr Frances’ integrity. Dr Frances was accused of arguing because of anticipated personal financial gain. The accusation that Dr Frances was arguing ad hominem was the pot calling the kettle black.
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.
Arnold Knepfer, MD Read more!
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.
Arnold Knepfer, MD Read more!
Like Writing a Letter to Santa Claus
A reader sent us a note regarding his experiences in providing feedback to the DSM-V committee:
"I responded to the chance to upload to the DSM-V website an article I published with suggested DSM-V criteria for addiction - perhaps 6 months ago. There was never a response. My comments went off into cyberspace. I had my administrator try to follow up with a call to the head of the DSM-V committee, Charles O'Brien, MD. No response. So while it is true that there is a way to “give input,” there is no evidence that anyone on the DSM-V committee I wrote to ever saw the input. It was like writing a letter to Santa Claus at the North Pole.
Brian Johnson M.D.
Director of Addiction Psychiatry
SUNY Upstate Medical University"
How do you feel the DSM-V committee should handle feedback? Should a more public "sounding ground" be offered, such as a forum or Facebook?
Check out our DSM-V page for updates! Read more!
"I responded to the chance to upload to the DSM-V website an article I published with suggested DSM-V criteria for addiction - perhaps 6 months ago. There was never a response. My comments went off into cyberspace. I had my administrator try to follow up with a call to the head of the DSM-V committee, Charles O'Brien, MD. No response. So while it is true that there is a way to “give input,” there is no evidence that anyone on the DSM-V committee I wrote to ever saw the input. It was like writing a letter to Santa Claus at the North Pole.
Brian Johnson M.D.
Director of Addiction Psychiatry
SUNY Upstate Medical University"
How do you feel the DSM-V committee should handle feedback? Should a more public "sounding ground" be offered, such as a forum or Facebook?
Check out our DSM-V page for updates! Read more!
No One Owns Us, No Matter Who Has Sold Us
Thank you Dr. Frances for making explicit what has been an implicit, sad trend in our profession. I also believe we have slowly sold out to the pharmaceuticals. Perhaps, first, it was to legitimize ourselves as part of "real" medicine. I could have lived with the psychiatry of twenty or even ten years ago. The pens, dinners, and drug samples did not pose any heart-wrenching ethical dilemmas for me or any colleague I knew. But these past ten years, there's been a creeping toxic alliance between big business (insurance, big pharm) and our professional elite. And this sell-out has nothing to do with plastic perks. We have invited the drug companies to dictate our theories and diseases and support our research for answers that sell their products. The only folks who don't recognize this as self-serving and transparent are us.
The overselling of pharmaceuticals by psychiatric "spokes-professionals" has saddled the hard-working private Docs with the credibility gap of a used-car salesman. That's why people are running to alternative medicine. Given the recent news, why shouldn't someone wonder if we’re hyping meds to "guarantee" repeat business?
And what about the quality of our own professional life? We're left with a field that chokes on creativity and once embraced innovations. Now, anyone who does not march to the drum-beat of evidence-based medicine risks censure, although the limitations of this model have been extensively exposed.
I agree with Dr. Frances that classifications used by practitioners should be created or at least informed by them. We are the professionals who have a grasp of those who get ill. Those who conceptualize patients in terms of significant deviations and benign to severe symptoms will not know them, nor see obvious truths. Right now, one obvious truth is people are angry with us and it's not a part of their diagnosis. They need to trust the integrity of professional they see. How can they, given the above? Would we?
What Dr. Frances describes is a nightmare - new diseases to pathologize more of "normal" life that will need more medication. Throw in electronic medical records and no one will dare go to us, for fear of being branded with a four digit code. (Yes, I mean that allusion. How many readers remember our protests to Soviet psychiatry?)
I agree with Dr. Frances that the DSM, our "Bible" implies more than metaphorical weight. We need to think carefully now. What we define as illness also implies what's healthy. This "Bible" will imply that those who do “adapt" to our stressed-filled, detached, and achingly competitive lifestyle are adjusted. Since many of us share that life, we may not want to look at it too closely.
Do we agree? If you are over 40, you have witnessed a rocket acceleration of changes in how we live. During this time, our profession has adopted a complaint posture, one that accedes to conformity, going with a flow and being on top of it. We don't think to buck it, anymore. And the flow now is materialism which dictates that cost-effective is a synonym for "right" and "best." We have been instrumental in promoting that equation so we should ponder the truth of this, at least a little.
And unless we get totally discredited by our more ambitious colleagues, like it or not, we psychiatrists are still the "Priests of Normality. If we take our role with any gravity, we might ask ourselves whether the lifestyle we endorse as "normal” really nurtures healthy.
Whether or not you believe we have sold out to big pharm, whether or not you think medications are the answer for all ills are no longer important. As Dr. Frances implies, there are bigger "fish frying" and more than our professional integrity or power at stake.
The past ten years, our profession has joined hands with big business and politicians and marched an increasingly materialistic road, from the medicine we practice (in which personality is reduced to DNA and neurotransmitter concentrations) to the values that guide us (bottom line bucks.) Meanwhile, we are bleeding soul and courage, words that will never be found in any DSM, ever. But we know them and feel a gnawing void when they are not present.
Maybe we got so entrenched in materialism for the same reasons our culture did. That doesn't mean we have to remain so. As "Priests of Normality," we could concern ourselves with making "normal" more humane, rather than "making" a DSM that makes mental illness more pervasive. We could use the credibility we have left to make businesses more family-friendly. We might have more healthy children. We could focus on people empowering themselves to take charge of their out-of-control lives. Why should we push pills to "help" people adapt to what's making them sick? We could change the focus of who we are. We could stop being prescribers.
No one owns us, no matter who has sold us.
Peggy Finston MD
Prescott, Arizona Read more!
The overselling of pharmaceuticals by psychiatric "spokes-professionals" has saddled the hard-working private Docs with the credibility gap of a used-car salesman. That's why people are running to alternative medicine. Given the recent news, why shouldn't someone wonder if we’re hyping meds to "guarantee" repeat business?
And what about the quality of our own professional life? We're left with a field that chokes on creativity and once embraced innovations. Now, anyone who does not march to the drum-beat of evidence-based medicine risks censure, although the limitations of this model have been extensively exposed.
I agree with Dr. Frances that classifications used by practitioners should be created or at least informed by them. We are the professionals who have a grasp of those who get ill. Those who conceptualize patients in terms of significant deviations and benign to severe symptoms will not know them, nor see obvious truths. Right now, one obvious truth is people are angry with us and it's not a part of their diagnosis. They need to trust the integrity of professional they see. How can they, given the above? Would we?
What Dr. Frances describes is a nightmare - new diseases to pathologize more of "normal" life that will need more medication. Throw in electronic medical records and no one will dare go to us, for fear of being branded with a four digit code. (Yes, I mean that allusion. How many readers remember our protests to Soviet psychiatry?)
I agree with Dr. Frances that the DSM, our "Bible" implies more than metaphorical weight. We need to think carefully now. What we define as illness also implies what's healthy. This "Bible" will imply that those who do “adapt" to our stressed-filled, detached, and achingly competitive lifestyle are adjusted. Since many of us share that life, we may not want to look at it too closely.
Do we agree? If you are over 40, you have witnessed a rocket acceleration of changes in how we live. During this time, our profession has adopted a complaint posture, one that accedes to conformity, going with a flow and being on top of it. We don't think to buck it, anymore. And the flow now is materialism which dictates that cost-effective is a synonym for "right" and "best." We have been instrumental in promoting that equation so we should ponder the truth of this, at least a little.
And unless we get totally discredited by our more ambitious colleagues, like it or not, we psychiatrists are still the "Priests of Normality. If we take our role with any gravity, we might ask ourselves whether the lifestyle we endorse as "normal” really nurtures healthy.
Whether or not you believe we have sold out to big pharm, whether or not you think medications are the answer for all ills are no longer important. As Dr. Frances implies, there are bigger "fish frying" and more than our professional integrity or power at stake.
The past ten years, our profession has joined hands with big business and politicians and marched an increasingly materialistic road, from the medicine we practice (in which personality is reduced to DNA and neurotransmitter concentrations) to the values that guide us (bottom line bucks.) Meanwhile, we are bleeding soul and courage, words that will never be found in any DSM, ever. But we know them and feel a gnawing void when they are not present.
Maybe we got so entrenched in materialism for the same reasons our culture did. That doesn't mean we have to remain so. As "Priests of Normality," we could concern ourselves with making "normal" more humane, rather than "making" a DSM that makes mental illness more pervasive. We could use the credibility we have left to make businesses more family-friendly. We might have more healthy children. We could focus on people empowering themselves to take charge of their out-of-control lives. Why should we push pills to "help" people adapt to what's making them sick? We could change the focus of who we are. We could stop being prescribers.
No one owns us, no matter who has sold us.
Peggy Finston MD
Prescott, Arizona Read more!
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