DSM-5: a fatal diagnosis?
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3256 (Published 22 May 2013) Cite this as: BMJ 2013;346:f3256
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There was a factual slip in my rapid response under above title posted up 1 June. The Miami Herald article I referred to was dated 30 May 2012, not 2013.
Competing interests: No competing interests
An interesting article. The criticisms of diagnosis in psychiatry would carry more weight if those familiar critics (both within and outside psychiatry) offered clear and viable alternatives to the existing classification systems which include (but is often not appreciated by non-medical commentators) the all important medical clinical concept of recognisable and widely agreed morbidity (symptoms on their own are not enough) in addition to acknowledging the well established method of psychiatric formulation which should occur in all good psychiatric practice(1). One could wonder therefore whether the recent statement from clinical psychologists (2) adds anything clinically tangible to the debate, but perhaps rather develops a continuing political pose of some psychologists. Those who know what psychiatrists do would recognise that they are pragmatic practitioners when dealing with the so-called functional psychiatric conditions, well aware of the nuances of those conditions and not rigidly beholden nor frequently consulting an imperfect, but useful, descriptive system, when combined with clinical experience.
(1) Psychiatric Examination: Notes on Eliciting and Recording Clinical Information in Psychaitric Patients. The Departments of Psychiatry and Child Psychiatry. The Institute of Psychiatry and The Maudsley Hospital London. Second Edition Oxford Medical Publications 1987
(2)The British Psychological Society - Division of Clinical Psychology - Classification of behaviour and experience in relation to functional psychiatic diagnosis. Time for a paradigm shift. DCP Position Statement May 2013
Competing interests: No competing interests
Editorial note: This response was modified on legal advice on 7 June 2013.
In his article on DSM-5, discussing conflicts of interest, Jonathan Gornall refers to the case of Emory University Professor Charles Nemeroff, who concealed huge payments made covertly to him by GlaxoSmith Kline, makers of the anti-depressant paroxetine, whilst lead investigator on a National Institutes of Health study of that very drug. Nemeroff was obliged to resign from Emory but was then appointed chair of psychiatry at the University of Miami. The Miami Herald reported this week (30 May) that Senator Charles Grassley, chair of US Senate Committee on Finance, had written to the National Institutes of Health to ask why they had recently granted Nemeroff $400,000 per year for 5 years when he remains under federal investigation.
None of this appears to concern the Institute of Psychiatry, King’s College London, a research establishment with an international profile. The Institute has invited Professor Nemeroff to give the inaugural Annual Lecture of its new Centre for Affective Disorders on 17 June, describing him as “one of the world’s leading experts in the neurobiology of depression”.
The Nemeroff case tells us something about how the psychiatric establishment and the biomedicine-driven research world work, and about their relationship with the pharmaceutical industry that has a vested interest in the biologisation of human experience- indeed in the disease- mongering Jonathan Gornall reprises. Nemeroff’s appointment to another chair of psychiatry as if nothing had happened and when the case against him was not closed, his receipt of substantial new grants, and the Institute of Psychiatry in London continuing to laud him as “one of the world’s leading experts”, all show how psychiatric academe sails blithely on as if such revelations beg no broader questions about its associations and supposed scientific independence, about research ethics, and specifically how conflicts of interest must inevitably contaminate the integrity of the research data informing publications in the scientific literature.
It is worth adding that in fact no clinically meaningful “neurobiology of depression” has been discovered- and perhaps never will be, given that “depression” is merely a syndromal category, subsuming a very heterogeneous range of patients and circumstances,and whose widely differing understandings of their distress point rather more often to social space than to the space between their ears.
Competing interests: No competing interests
I would like to offer my support for Dr Timimi's call for the end of psychiatric diagnosis. This is, as many readers will know, also the view recently articulated in the Division of Clinical Psychology's Position Statement on Classification (available from www.bps.org.uk), which calls for 'a paradigm shift not based on a "disease" model' (p.1.) The alliance between critical psychiatrists, psychologists and service users, along with many other concerned groups, makes it clear that the inaccurate media spin of this debate as a kind of 'turf war' will not defuse the arguments. When Mental Health Europe declares that 'Western psychiatry is in crisis' and warns that the biomedical model can 'encroach on basic human rights', it is time to re-examine our most fundamental assumptions about the nature and causes of mental distress.
Competing interests: Member of DCP working party on Position Statement on Classification
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
Psychiatric conditions, like many chronic diseases, have a wide spectrum of severity.
As Gornall reports, the psychiatrists on the DSM-5 panel are likely to champion disorders in which they have a clinical or academic interest, often at the more severe end of the spectrum. As one of the key criticisms of DSM-5 is overdiagnosis and medicalising everyday emotions, it seems bizzare that there is no representation from primary care doctors, who are better placed to recognise the important grey area at the less severe end of the spectrum.
Although DSM-5 relates to psychiatric diagnoses, clinical generalists could provide valuable insights into social context and medical multimorbidity. This may help to produce a more balanced and relevant model to catalogue mental illness.
Competing interests: No competing interests
Re: DSM-5: a fatal diagnosis?
Once more the AMA fails to acknowledge FAS / ARND [ FASD ]
Unfortunately the new diagnosis [ four grades ] of Intellectual Disability is going to be used for all those children who do not meet the requirements for autism and adhd etc and are actually FASD. Pediatricians and child psychiatrists will have no need to pursue the question of PAE, something I saw on a daily basis in practice.
Where the evidence of PAE cannot be ignored the new diagnosis of ND – PAE [ code 315.8 ] will be used creating even more confusion for those with FASD and the families that support them.
Barry Stanley
www.barrystanleyfasd.com
Competing interests: No competing interests