Re: DSM-5: a fatal diagnosis?. Jonathan Gornall. 346:doi:10.1136/bmj.f3256

The recent debate on DSM-5 goes much deeper than whether DSM-5 is better or worse than DSM-IV or ICD 10. The shortcomings, such as no markers, difficulties understanding the difference between normal and pathological states, and conflict of interest problems is just the tip of the iceberg of the dysfunctional nature of all psychiatric diagnostic systems, issues that no diagnostic system, past, present, or future is likely to solve. As has been pointed out in many publications, including the 'No More Psychiatric Labels' campaign (1) and a recent special article in the British Journal of Psychiatry co-authored by 29 members or fellows of the Royal College of Psychiatrists (2), the technical model for understanding mental health (based on notions that diagnosis helps us differentiate discrete identifiable pathological processes, which can then advance scientific knowledge and clinical practice) has not led to any breakthroughs in scientific knowledge or improved outcomes. The evidence is clear: psychiatric diagnoses remain unreliable, are not associated with any biological or psychological markers, do assist treatment decisions as matching treatment model to diagnosis has no differential clinically significant impact on outcomes, is associated with increased stigma, leads to colonisation of mental health models in the non-industrialised world, despite the better long term outcomes there, and is associated with rapidly growing numbers receiving a diagnosis without accompanying evidence that such a process leads to better long term outcomes.

The problem of poor long term outcomes seems to be one the leadership in our profession wish to bury their heads in the sand about. As another paper in this weeks BMJ finds (3) the mortality gap between psychiatric patients and the general population in Western Australia increased between 1985 and 2005. Whilst the linked editorial (4) raises many pertinent reasons that need addressing to help reverse this process, it avoids mention of anything that may implicate the core practice of the profession (such as the role the toxic medications we use may play). Our models and treatments are letting our patients down and letting them down badly. This unacceptable and sorry state of affairs is likely to continue whilst we remain wed to systems of practice that are associated with these worsening long term outcomes.

Professionals from across mental health disciplines are now coming together with service user organisations to complain about current institutional practice and campaign for genuine reform of services to get them to move away from diagnostic based paradigms towards those that prioritise meanings, narratives and ethics in a way that promotes a robust recovery culture that fully includes the voice and real life contexts of service users. I, like many psychiatrists, hope that the publication of DSM 5 has ignited a public debate that will inspire a revolution in mental health practice, one that will put an end once and for all of the use of psychiatric diagnoses.

References:
1. Timimi S. No more psychiatric labels. International Critical Psychiatry Network. 2011. www.criticalpsychiatry.net/?p=527.
2.Bracken P, Thomas P, Timimi S. et al. Psychiatry beyond the current paradigm. BJPsych 2012;201:430-434.
3.Lawrence D, Hancock KJ, Kiseley S. The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013;346:f2539.
4. Thornicroft G. Premature death among people with mental illness. BMJ 2013;346:f2969.

Competing interests: I am a member of the Critical Psychiatry Network

Re: Influenza: marketing vaccine by marketing disease. Peter Doshi. 346:doi:10.1136/bmj.f3037

Here in our model, modern, Western Democracies (the UK and the USA), we could dismiss Dr Vlassov's account of Russian Flu Vaccine reactions as things that happen in totalitarian regimes. No opportunity for market competition. No freedom for the physician to do his best for the patient who is a supplicant in front of him.

We could teach the serfs a thing or two.

Here, in the Land of the Free (USA) and the Mother Country of the Commonwealth, the Empire (the UK), we have the spectacle of Marketing Disease, Drugs of Poor Benefit being issued for use by our Democratic Government - please see Dr PM English's rapid response - the promotion of vaccination programmes without answering queries raised in the Rapid Responses (a debating forum meant to look at issues of interest in Medicine, as highlighted in the BMJ - please see the contributions from Dodge, Struthers, Havinga, Anand ie, myself ) in All Rapid Responses in the past one month.

The tacit acceptance of the government policies and practices by the GPs, Consultant Physicians, Public Health Physicians, Academics, the refusal to debate; in effect deafening silence.

Does all the above make us in the UK and the US, the shining beacon that the dark, unenlightened Third World should travel to?

Answers, please, to the specific points raised in the previous rapid responses. This is merely a pointer.

Competing interests: Still seeking facts

Re: Pelvic inflammatory disease. Emily C Bartlett, Wendy B Levison, Pat E Munday. 346:doi:10.1136/bmj.f3189

mycoplasma genitalium is involved in 40% of pid and is not detected in routine chlamydia, gonorrhoea swabs. This was demonstrated in study reported in american journal obstetrics last year, where mycoplasma genitalium was looked for as well as gonorrhoea and chlamydia.[1]

1 Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Am J Obstet Gynecol 2012;206:476.e1-8.

Competing interests: None declared

Re: Indian government allocates nearly half its disaster budget for drought relief in Maharashtra. Patralekha Chatterjee. 346:doi:10.1136/bmj.f1902

Civilization is water management for human betterment, not nature's detriment.

Competing interests: None declared