Is The Criticism of DSM-5 Misguided? Part II

A few months ago, I wrote about how critics of the DSM-5 (led by Allen Frances, editor of the DSM-IV) might be barking up the wrong tree.  I argued that many of the problems the critics predict are not the fault of the book, but rather how people might use it.  Admittedly, this sounds a lot like the “guns don’t kill people, people do” argument against gun control (as one of my commenters pointed out), or a way for me to shift responsibility to someone else (as another commenter wrote).  But it’s a side of the issue that no one seems to be addressing.

The issue emerges again with the ongoing controversy over the “bereavement exclusion” in the DSM-IV.  Briefly, our current DSM says that grieving over a loved one does not constitute major depression (as long as it doesn’t last more than two months) and, as such, should not be treated.  However, some have argued that this exclusion should be removed in DSM-5.  According to Sidney Zisook, a UCSD psychiatrist, if we fail to recognize and treat clinical depression simply because it occurs in the two-month bereavement period, we do those people a “disservice.”  Likewise, David Kupfer, chair of the DSM-5 task force, defends the removal of the bereavement exclusion because “if patients … want help, they should not be prevented from getting [it] because somebody tells them that this is what everybody has when they have a loss.”

The NPR news program “Talk of the Nation” featured a discussion of this topic on Tuesday’s broadcast, but the guests and callers described the issue in a more nuanced (translation: “real-world”) fashion.  Michael Craig Miller, Editor of the Harvard Mental Health Letter, referred to the grieving process by saying: “The reality is that there is no firm line, and it is always a judgment call…. labels tend not to matter as much as the practical concern, that people shouldn’t feel a sense of shame.  If they feel they need some help to get through something, then they should ask for it.”  Bereavement and the need for treatment, therefore, is not a yes/no, either/or proposition, but something individually determined.

This sentiment was echoed in a February 19 editorial in Lancet by the psychiatrist/anthropologist Arthur Kleinman, who wrote that the experience of loss “is always framed by meanings and values, which themselves are affected by all sorts of things like one’s age, health, financial and work conditions, and what is happening in one’s life and in the wider world.”  Everyone seems to be saying pretty much the same thing:  people grieve in different ways, but those who are suffering should have access to treatment.

So why the controversy?  I can only surmise it’s because the critics of DSM-5 believe that mental health clinicians are unable to determine who needs help and, therefore, have to rely on a book to do so.  Listening to the arguments of Allen Frances et al, one would think that we have no ability to collaborate, empathize, and relate with our patients.  I think that attitude is objectionable to anyone who has made it his or her life’s work to treat the emotional suffering of others, and underestimates the effort that many of us devote to the people we serve.

But in some cases the critics are right.  Sometimes clinicians do get answers from the book, or from some senseless protocol (usually written by a non-clinician).  One caller to the NPR program said she was handed an antidepressant prescription upon her discharge from the hospital after a stillbirth at 8 months of pregnancy.  Was she grieving?  Absolutely.  Did she need the antidepressant?  No one even bothered to figure that out.  It’s like the clinicians who see “bipolar” in everyone who has anger problems; “PTSD” in everyone who was raised in a turbulent household; or “ADHD” in every child who does poorly in school.

If a clinician observes a symptom and makes a diagnosis simply on the basis of a checklist from a book, or from a single statement by a patient, and not on the basis of his or her full understanding, experience, and clinical assessment of that patient, then the clinician (and not the book) deserves to take full responsibility for any negative outcome of that treatment.  [And if this counts as acceptable practice, then we might as well fire all the psychiatrists and hire high-school interns—or computers!—at a mere fraction of the cost, because they could do this job just as well.]

Could the new DSM-5 be misused?  Yes.  Drug companies could (and probably will) exploit it to develop expensive and potentially harmful drugs.  Researchers will use it to design clinical trials on patients that, regrettably, may not resemble those in the “real world.”  Unskilled clinicians will use it to make imperfect diagnoses and give inappropriate labels to their patients.  Insurance companies will use the labels to approve or deny treatment.  Government agencies will use it to determine everything from who’s “disabled” to who gets access to special services in preschool.  And, of course, the American Psychiatric Association will use it as their largest revenue-generating tool, written by authors with extensive drug-industry ties.

To me, those are the places where critics should focus their rage.  But remember, to most good clinicians, it’s just a book—a field guide, helping us to identify potential concerns, and to guide future research into mental illness and its treatment.  What we choose to do with such information depends upon our clinical acumen and our relationship with our patients.  To assume that clinicians will blindly use it to slap the “depression” label and force antidepressants on anyone whose spouse or parent just died “because the book said so,” is insulting to those of us who actually care about our patients, and about what we do to improve their lives.

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61 Responses to Is The Criticism of DSM-5 Misguided? Part II

  1. Jaen Wirefly says:

    Has there been any confirmation that personality disorders are going to be moved to Axis I?

    BTW-Insightful blog.

  2. Rob Lindeman says:

    !!! Thank you for revisiting; I’ll re-post essentially the same comment I made the first time round:

    The rest of the world, particularly the lay world, doesn’t see the DSM the same way you do. DSM labels, and labels become entities with independent existence. This way grief after loss becomes reified as a bona fide disease. That, grossly over-simplified, is the problem.

  3. Nathan says:

    Again, perhaps this is an important are of psychiatric practice/knowledge that requires psychiatrists to be incredibly clear (and in writing) about the the intended use of the DSM. Rob is right in that DSM diagnoses regardless of changes in people’s experiences can stick a long time, become problematic in legal frameworks, complicate insurance claims, and many individuals find them stigmatizing (and can hinder recovery). I am ok with the idea of a finding associations between clusters of symptoms to be able to tacitly be called a disorder in order to see if treatments can be helpful across those constellations of symptoms, but I think that it needs to be clear that the diagnoses do not have actual validity and diagnostic labels need to disappear after symptoms abate.

    To modify your analogy “the DSM doesn’t misdiagnose/treat people, clinicians do,” So clinicians, particularly psychiatrists (who have the sole ownership of the DSM enterprise that is used as legal evidence, determining coverage, determining access to benefits, etc.) need to take ownership of poor diagnosis and treatment without citing the DSM. “I was just following the DSM” or “I went with my experience without much regard for the DSM” both become . However, I fear that psychiatrists will get too much benefit of the doubt if they don’t have some agreement on diagnostic category and treatments, but then continue to diagnose and treat without telling patients that. I am already hearing “you know we were just trying our best, because we really are just flying by the seat of our pants” arguments when things go wrong.

    The DSM is a force in itself, so either psychiatrists have to accept the power they have invested in it and live with the consequences, or be very clear and actively work to change how the DSM is perceived/used and consider a guideline for clinical practice/research, but then also have to come clean about what they do base their decisions/diagnoses/treatments etc. on and how valid/reliable/helpful those are.

    • stevebMD says:

      Nathan:

      I agree, except for one thing: “…psychiatrists (who have the sole ownership of the DSM enterprise…)” This is not true. I dont’ know if this is what you meant, but the DSM is used by lots of people: PhDs, PAs, LCSWs, MSWs, MFTs, LMFTs, RNPs, CDACs, not to mention all the other MD/DO doctors who aren’t psychiatrists yet treat mental illness in their patients. In one community clinic where I work, patients are usually seen by one or two non-MD screeners before they see me, and their intake forms already include a diagnosis, straight from the DSM (and sometimes even with narrative copied directly from the text: “Mr. XX avoids situations or endures them with distress and anxiety about having another Panic Attack, or he requires the presence of a companion. His anxiety is not better accounted for by another mental disorder.” — I kid you not). Furthermore, with the advent of EMRs, if a family practice doc (say) prescribes a “trial” of an SSRI because he thinks a patient has mild depression, then he’s often forced to enter “depression” or “depression NOS/NEC” in the “problem list,” which then becomes a 296.3 or 311 (DSM codes) as a permanent part of that patient’s chart, even though no psychiatric assessment was done.

      Otherwise, what you write is accurate. We do need to change how the DSM is perceived/used. But it’s going to be an uphill battle, since so many people are comfortable with how it’s used right now– not to mention completely oblivious to the fact that there’s even a debate like this going on (don’t get me started down that path!).

      • Nathan says:

        I say psychiatrists “own” the enterprise because the APA is the one that writes, approves, sells, and profits from it. Other mental health professionals use the DSM because it has become so ingrained and pervasive for insurance, treatment, and benefits purposes and creating/using alternative systems will not be funded, reimbursed, valid forensically or for benefits. Perhaps it is unfair to say psychiatry owns the enterprise and saying Psychiatry owns the enterprise is more resonant.

        As for non-psychiatrists using the DSM to make diagnoses using language for the text, I am not inherently bothered by it as long as there is an understanding that the validity of mental disorders is specious and all that is actually being reported are clusters of symptoms that organize in a way that seems to be more commonly associated than others, not necessarily an actual pathology or diagnostic label that stays with someone forever.

        Thank you for keeping the debate upfront in whatever channels you can.

      • Nathan says:

        I meant to say, “Perhaps it is unfair to say psychiatrists own the DSM enterprise and saying Psychiatry owns the enterprise is more resonant.”

  4. Jackie says:

    On the subject of labels — why does “The Carlat Psychiatry Blog” get top billing above?

  5. Carolyn Thomas says:

    Hello Dr. C – there appears to be a far bigger issue here than simply how the DSM-5 might be misused (although your paragraph on this is frightening enough). The more important concern seems to be the pervasive medicalization of everyday life – and bereavement is a prime example.

    My mother died on February 21st. The sadness and sense of loss I felt (and still feel) could be considered pathological by some (and surely a reason to reach for the prescription pad) but it could also be considered to be, well, “normal” sadness and sense of loss.

    From shyness to rudeness to childhood temper tantrums, we’ve observed the relentless expansion of pharmaceutical solutions to otherwise “normal” life problems that can be fixed by drugs. The field of psychiatry has indeed given us the ‘poster children’ for this medicalization.

    Consider also that earlier editions of the DSM clearly defined homosexuality, for example, as a mental disorder – until the APA decided (what were they thinking?) to hold their 1970 convention in San Francisco, where the gay liberation movement was at its peak after the Stonewall Riots. Next thing you know – the DSM suddenly decides that homosexuality “is not and never has been a mental illness”. More on this at: “How the Shrink’s Bible Can Make You Sick” – http://ethicalnag.org/2011/07/02/dsm-5-shrinks-bible/

    • I agree with what Carolyn Thomas writes here about medicalizing everyday life. As I see it, that’s the real issue.

      Bereavement has been in DSM at least since DSM-III in 1980. It’s a v-code, V62.82 to be specific, an “other condition that may be a focus of clinical attention.” And its description in DSM-IV-TR (the current edition) strikes me as pretty thoughtful. It says bereavement can be a focus of clinical attention, that it can share many symptoms of major depression, but that a major depression diagnosis is “generally” not given within the first 2 months of bereavement. It goes on to describe atypical symptoms that “may be helpful in differentiating bereavement from a Major Depressive Episode.” This, to me, implies that an abnormal grief reaction can indeed be diagnosed as depression, but that typical grief reactions should not be.

      The effort now to remove the bereavement exclusion from diagnosing Major Depression is essentially political, a noxious pathologizing of normal human experience. As shyness became social anxiety disorder and temper tantrums became ADHD or childhood bipolar disorder, normal human reactions after the death of a loved one may soon be a psychiatric diagnosis. The DSM doesn’t dictate how good psychiatrists practice, but that doesn’t mean we should ignore its publication either. Sure, DSM-V will inevitably have flaws — let’s seek to minimize them.

      • stevebMD says:

        Dr Reidbord: “its description in DSM-IV-TR (the current edition) strikes me as pretty thoughtful.”

        Thank you for writing that. In preparing the post, I reviewed the V62.82 description and was equally impressed. It may very well help a clinician to distinguish between a “normal” grief reaction and depression, thereby turning (to use Dr Allen’s phrase) a “bad doctor” into a “good [or at least better] doctor.”

        It should be said that the entirety of the DSM (the full version) offers equally helpful observations and clarifications. It can get dense at times, and one can certainly question its validity, but overall, the book is far more comprehensive than the “checklists” or “Chinese-menu” symptom lists that we like to disparage.

      • I agree there’s value in the discussion portions of DSM, and in DSM overall. But my point above is that the Bereavement v-code has been a DSM-sanctioned “focus of clinical attention” for more than 30 years. Calling these very same presentations “disorders” that warrant “treatment” highlights the power of language, and why criticism of DSM-5 is not misguided. A diagnosis justifies 3rd-party payments, formal disability status, and drug sales, whereas a mere v-code does not. Hence, the eternal expansion of psychiatric diagnosis is not particularly surprising. Lost in this grand bargain are the shrinking territory called “normal,” and the legitimacy of seeing a mental health professional for emotional pain that falls short of a formal diagnosis. Language matters — a lot.

  6. Altostrata says:

    Dr. Steve, you say “If a clinician observes a symptom and makes a diagnosis simply on the basis of a checklist from a book, or from a single statement by a patient, and not on the basis of his or her full understanding, experience, and clinical assessment of that patient, then the clinician (and not the book) deserves to take full responsibility for any negative outcome of that treatment.”

    Absolutely true. So where are the feedback mechanisms to track those negative outcomes? In the US, other than the black hole of state medical boards, there’s no place for patients to send complaints. There are no psychiatry monitoring bodies. Any patient with a psychiatric diagnosis (a Catch-22 for most who have received psychiatric medication) is not considered credible in a lawsuit. And, while doctors are terrified of malpractice accusations, a psychiatrist pretty much has to kill a child before he or she can be disciplined.

    So how is responsibility for bad psychiatric practice brought home to the clinician?

    From where I sit, clinical psychiatrists who get to know anything about their patients lives before prescribing are the minority, and then there are the darn GPs, who definitely are arbitrarily and reflexively prescribing psychiatric drugs based on bowdlerized information.

    In my opinion, the furor over DSM-5 is not only justified — psychologists find it distasteful — but opens necessary debate about the role of psychiatry in medicine. It has also provided focus for protest by professionals against the excesses of biological psychiatry, which so staunchly stood for “chemical imbalance” for 20 years. If psychiatry can be wrong about that, it can be wrong about the whole ball of wax.

    I agree, ultimately the finger should be pointed at bad doctors, rather than a book. Who among you is going agitate for more oversight of clinical practice?

    • stevebMD says:

      Alto: “Who among you is going agitate for more oversight of clinical practice?”

      The main problem is that there’s no one to agitate to. If I express my concerns to my supervisors, medical directors, colleagues, or teachers, they fall on deaf ears (occasionally there will be an expression of sympathy, followed quickly by “but that’s just the way it is”). Or worse– I might be labeled a disruptive physician. Where do I go next? The APA (where my voice is definitely in the minority)? The state medical board (where they’re more interested in my personal life than in whether my patients get appropriate care… trust me on this one)? The massive bureaucracy of an insurance company (where I can’t even figure out which phone number to call to get a question answered)? My congressperson? President Obama?

      The other problem, which I alluded to in a previous comment, is that so many clinicians accept this uncritically. Most GPs who, I agree, are “arbitrarily and reflexively prescribing psychiatric drugs based on bowdlerized information” would absolutely reject this characterization. They’re providing valuable mental-health services, darnit! And I’ve heard many a doctor say “thank god for the drug reps– they’re the way I keep up with the current research.” When you combine strong egos with limited access to objective information, and an unwillingness to be self-critical, you’ve created an enclosed system which is difficult to repair, not to mention ripe for abuse by outsiders (e.g., Big Pharma, malpractice lawyers, for-profit insurance companies, drug-seeking patients, medical-marijuana proponents, single-payer health care advocates) who have figured out how to game it. I’m almost ashamed to call myself a physician sometimes.

      • Altostrata says:

        We agree it’s a closed system and anosognosia reigns. (See http://opinionator.blogs.nytimes.com/2010/06/20/the-anosognosics-dilemma-1/ )

        Just so, you might consider the DSM-5 protest as a symbolic wedge issue. It’s one of the few places the system is vulnerable.

        And surely the proliferation of unnecessary diagnoses that exist only in academic discussion is undesirable?

      • mara says:

        “The state medical board (where they’re more interested in my personal life than in whether my patients get appropriate care… trust me on this one)?”

        I know this isn’t something you probably enjoy talking about, but I was reading about the stuff you got in trouble for…and I was surprised, because you don’t seem like the type…but I actually didn’t know that doctors could be sanctioned for stuff like that. Some of it really was your personal business, and I have no clue how the med board found out about it. But the other infractions that were of a legal nature had nothing to do with medicine. And it’s not like you killed someone. I could understand if you had committed a felony…but your issues sounded kinda minor. At least from what I read…

  7. The DSM says clearly that clinical judgment is always necessary when deciding the significance of a symptom, so you’re not supposed to use it like a cookbook.

    But everyone’s right – that doesn’t stop doctors and non-doctors alike from using in that way.

    • Nathan says:

      Ultimately Dr. Allen, clinicians come to a diagnosis for all sorts of reasons (clinical judgement after thorough evaluation, for insurance purposes, patient peace of mind, etc.), and the diagnoses that have meaningful resonance are the ones listed in the DSM. These diagnoses are diagnosed by assessing the presence of various symptoms and criteria. While I agree that clinical judgement is important, I believe it is across the board poorly integrated in the diagnostic/treatment system, prone to all sorts of clinician/facility bias, and often arbitrarily considered. This is problematic because diagnoses become so significant in people’s treatment and many other aspects of their life. I hate sounding like I’m for “checklists” or “algorithms” because those seem to have such a bad rap here, but one of the benefits of having a symptom based diagnostic system is that it can at least be reliable. People have just started believing that it is also valid, which is not at all the case. Clinical judgement may not add all that much to diagnostics or treatment planning. I have not seen studies in psychiatry that compare experimentally algorithmic diagnosing/treating to ones more informed by clinical judgement. Studies from other medical specialties would indicate that clinical judgement informed diagnosing/treating does not lead to better outcomes generally, and is sometimes beaten by good algorithms. I know it’s tougher in psychiatry to think in such a way because there are a lot of factors, but algorithms are designed to weigh the most importants ones in deciding treatments that lead to the best health outcomes on average.

      • Nathan,

        I agree with some but not all of what you say.

        Of course, some doctors’ clinical judgment is no better than what they’d get if they just used a checklist. That’s why there are good doctors and bad doctors.

        Some of the syndromes described in the DSM have been described fairly consistently for centuries, while others are obviously just cobbled together by Pharma shills and blowhards with big egos like Biederman and Akiskal.

        Of course there are also patients who are highly atypical and do not fit into any neat categories.

        However, having said all that, if you’ve been seeing and treating patients who are really manic, for instance, (not just “agitated” or “irritable”), it ain’t subtle. Especially if you evaluate the psychosocial context in which the symptoms occur, which is exactly what is missed by those using a symptom checklist. See my post http://davidmallenmd.blogspot.com/2010/07/counting-symptoms-that-dont-count.html

      • stevebMD says:

        Dr Allen,

        I agree that experience is extremely valuable, and yes, truly “manic” patients present in a particular (and particularly memorable) way. But I’m confused when you say that the presentation is “not subtle” especially when you “evaluate the psychosocial context.” If it’s not subtle (i.e., it’s obvious), shouldn’t the psychosocial context be irrelevant? Or are you saying precisely the opposite– namely, that what’s “manic” in one psychosocial context may not be in another?

        If you mean the latter, I’m afraid you’re leading down a very slippery slope, one in which clinicians (even “good” ones) might see pathology where it may not truly exist, simply because of the “context” in which appears– thereby ruining the validity of the DSM even further.

        By the way, thank you for the link to your post. It’s a worthwhile read.

      • Nathan says:

        Dr. Allen,

        Good doctor/bad doctor excuses just doesn’t cut it for me. Patients have no good way of knowing who is a good doctor and who is a bad doctor, so we really have to assume (at best) average doctor quality. Do we judge which medical school/residency attended? Fellowships? Grades? Testimonials? Nearly all psychiatrists are board certified, so does that credentialing mean anything special if there are still a lot of bad psychiatrists? Doctors do not advertise patient outcomes, and there is of yet any systemic way to compare doctors based on those and even then would be pretty contextual. And my point is that even “good” doctors do not perform better than “good” algorithms. If they do, what are those doctors attending to in their decision-making/behavior and how can we design better algorithms based on what those doctors do so more doctors can help their patients achieve better outcomes.

        I do question whether or not certain disorders have existed throughout centuries. Even if symptomatically they are similar, their meanings to people’s lives and communities, framework of what constitutes treatment (if anything), and the distress/impairment caused may have been quite different. We see these differences within our time/communities. Our understanding of mental illness is culture/history-bound (even the DSM sparsely adds culturally specific disorders just to show that.) The fact that the DSM has now gone through five editions and many revisions, with diagnostic frameworks of even what are considered the most enduring disorders changing substantially, and that is just since the 50s, illustrates this point. Additionally, that pharma influences, academic leaders with egos, and organized political action can lead to diagnostic inflation or challenge diagnoses also shows this point.

        As for determining who is “manic,” “irritable,” or “agitated,” it is precisely that the differences are only found in context that the validity of the term and underlying pathology is exposed as weak. I agree with you that some clinicians are really terrible at telling the large difference (even by current definitions), but whether determining the differences by diagnostic criteria, clinical assessment, a mix, or something else, it still does not get to the validity of the diagnoses/states as defined.

        This is why integration of DSM diagnoses into frameworks of law, other health, employment, public benefits, etc. is so dangerous. People do believe these diagnoses are valid and the people labelled with them carry them forever (regardless of their current symptoms). If doctors are not going to fight to try to disentangle the extent for which these diagnoses affect people’s lives (beyond their health), then at least they need to be tremendously cautious and humble about what is listed in the DSM and clear about how it should be used.

  8. Steve,

    Yes, the context still makes a difference. A patient who appears to be manic may actually be under the influence of cocaine, to cite an overly obvious example. But I’m amazed at the number of times I’ve seen psychiatrists label patients they know have taken cocaine as bipolar. The psychosocial context also includes the pervasiveness and the duration of symptoms. Someone having a rage attack after a big family fight can look manic, but only for a very short time. That’s what I’m talking about.

    Nathan,

    You’re right that the average person has no way of knowing who’s a good doctor and who isn’t. I was in medical school when my father-in-law was told to get a whirlpool treatment for a “muscle spasm,” when I could tell in five minutes that he had phlebitis because his leg was hot. I sent him back to the hospital and they admitted him. If he had had the whirlpool treatment, he could easily have had a pulmonary embolus and died!!

    I don’t know what we can do about bad doctors. The average patient would have just gone ahead and had the whirlpool treatment.

    Also, some diagnoses are very culture bound (borderline personality disorder) while others much less so. The content of the paranoid delusions in schizophrenia is often delusions about the FBI or the CIA following the person. If someone lived in India, it would obviously be about some other organization. But that’s a very minor difference.

    • Nathan says:

      Dr. Allen,

      It is distressing to hear that doctors diagnose mania if someone is on cocaine or another drug at the time of evaluation. That is particularly listed as an exception criteria (criteria E for a manic episode in the DSM-IV-TR.) That is just not avoiding context, but poor use of the DSM to boot . A computerized assessment really could screen for that very well so I don’t know what doctors who know or don’t ask if someone is using drugs are thinking or can maintain a practice/job. Someone having a rage attack usually won’t be having a rage attack for a week (the required amount of time someone needs to experience manic symptoms to be considered having a manic episode). Also, bipolar diagnoses require distinct manic and depressive episodes, so someone who just presents with mania, even during a rage attack, should not be diagnosed with a bipolar disorder. These don’t seem like good examples of why context is important, but these are below minimum competencies of contemporary psychiatric diagnosing. Because there are incompetent doctors, how much more important then it is to make the diagnoses in the DSM limited, clear, detailed, seen as only a “guide” and not stigmatizing labels that last forever.

      • Nathan,

        Just in case you thought I was dismissing the DSM criteria for different disorders, let me say that I am in favor of having them – and applying the actual criteria listed. (However, many of the new suggestions for the DSM-V are just pointless in the absense of new information about the etiology of the different diagnoses).

        But on the issue of clinical judgment being important, some grief reactions, for example, do in fact turn into major depressive episodes that DO respond to antidepressants – before the required waiting period specified in the current DSM has elapsed. Waiting would be a great disservice to the patient, needlessly prolonging their agony and perhaps increasing their risk for suicide. Psychiatrists should be, and have always been free, to treat them because the book says it is up to the doctor to judge the clinical significance of symptoms. Sometimes, grief is just grief. Other times, not. No symptom checklist that I know can ascertain this. But we don’t really need to change the DSM.

        A LOT lot of psychiatrists these days follow the lead of Akiskal and Biederman and just summarily dismiss the DSM duration criteria for manic or depressive episodes (which are admittedly somewhat arbitrary) as just being wrong, and use circular reasoning in journal articles to back their assertion. Some colleagues and I will have a letter published in the Archives of General Psychiatry in the next few months skewering just such an article that they published in an earlier edition.

      • Nathan says:

        All length of time for diagnoses are arbitrary because of the specious validity of the diagnoses. I believe, however, having pronounced length of time criteria can be helpful in limiting over-diagnosing and diagnostic inflation, limiting unnecessarily exposure to psychotropic medications that come with well known risks and side effects (and I would suppose some unknowns) and can add some more credibility and seriousness to a diagnosis.

        As for clinical determination of depression/grief, I say stick with the evidence gathered. Clinical diagnostic does not necessarily lead to good treatment or treatment based on any solid evidence. How do you determine which griefs have turned into depressions? How do you determine which are responsive to various kinds of treatments? How do you determine if someone is likely to not experience significant risk of off-label antidepressant use (including suicidal ideation and suicide)? Are patients informed that there is limited evidence (studies are sparse and the data in them does not show all that impressive of results) for antidepressants effect on grief reaction, what those effects are likely to be, and the risks involved?

        I understand that you want to minimize suffering of your patients and that patients also want that. These are admirable and ambitious goals. But if you act without solid evidence behind what you are doing, you have no way of being remotely confident that what you do can actually minimize suffering and may exacerbate it, all when someone is putting a lot of trust in you. We do know that grief overwhelmingly subsides and people who experience grief, complicated or otherwise, return to their typical selves without psychotherapy or antidepressants in reasonable amount of times (often before therapeutic effects of antidepressants or psychotherapy can really be present). I would generally (though not always specifically) err on the side of caution, recognize through some Bayesian reasoning that just watchful waiting with grief leads to good outcomes, and only intervene when risks for not doing so become apparent.

      • Nathan says:

        Dr. Allen,

        What I am trying to say is that you do have to make ipmortant decisions based on clinical experience and guess work. These are pretty fallible ways to make decisions, prone to all sorts of biases, attention or ignorance of irrelevant or important information, and I doubt psychiatrists en masse actually tell their patients that the research is not strong. I think this is should not be a a source of pride for psychiatrists and those working in clinical mental health.

        As a patient, I would not take years of experience over accumulated pictures presented by the data from well designed and conducted studies. I agree that a lot of studies (majority for sure) in psychopharmacology and psychotherapy have been” garbage”. This is unfortunate because a lot of time and money has been wasted doing poor research and the field in many ways has stagnated (at best). This does not mean that strong research should not be taken seriously, or that clinical experience trumps research because a lot of research is bad. As you say a lot of clinicians make terrible decisions based on all sorts of factors (their egos, money, beliefs, experience, etc.).

        I don’t think that the available research will always be enough to make confident diagnosing/treatment decisions, but I do think that when available it should anchor decision-making and more research should be done to fill gaps. And while everyone is different and people have different resilience, resources, responses, etc., because we do not have systematic ways of making good decisions about a lot of treatment for individuals, the best place to start is from what research tells about people’s response as a group (people = people with particular diagnoses/demographic profiles.)

        I really do believe that clinicians invest too much faith in their clinical experience/reasoning/helpfulness without being critical enough of how doing so can actually be useless or harmful when good data is available. I know I have read that nearly all therapists consider themselves to be in the to 50 percentile of effective therapists (making half of them incorrect in their faith in themselves). It would not necessarily be a bad thing to be in the lower percentiles if clinicians en masse engendered robust outcomes for their patients/clients. The problem is is that they don’t. I think it would be great if clinicians who utilize psychotherapies and drugs have expertise that are markedly helpful beyond other interventions. It would make sense because clinicians go through a lot of training and are paid a lot.I do think though, that more mathematical decision-making duplicates a great deal of outcomes that clinicians, and there are cheaper and more efficient ways to deliver treatment. I am not saying this because I support the reasoning of insurance companies and drug companies. Their motive is profit. My motive is maximizing health outcomes, minimizing harm, and optimizing/limiting cost/time patients have to invest in treatment.

        I am wary of faith in clinical judgement, especially when in wanton dismissal of available quality research (this is not directed at you.) Until clinicians can make good predictions about treatment outcomes, and having the outcomes they engender be better than other interventions (time, familial/community/peer support, etc.), they should be far more critical of their own judgement and patients should be wary of such judgement on what it is based on.

      • Nathan,

        I’m not saying good research should not be done, nor that it should be ignored. Nor am I saying that all clinical experience is created equal. I am saying that clinical research can be just as if not more biased than clinical experience, and each must be evaluated from the perspective that it is completely right AND the perspective that it is completely wrong.

        Both research and clinical experience must be evaluated to rule out, if possible, potential sources of biases, unaccounted for and contrary observations, and a whole host of other parameters. In other words, one must be just as critical of one source of data as the other, and take into account ALL sources of data before making a decision. In the final analysis, we deal with probabilities anyways, not certainties.

        Another point is that if clinical research were to claim to show, say, that the sky is actually red at noon on clear days and not blue, then the bar for evaluating that research has to be much higher than if the study confirms what we already think we know.

        Remember, there are no double-bind, placebo controlled studies on appendectomies for appendicitis, nor for parachutes in preventing deaths after falling out airplanes. ( I imagine you might still go with your personal observations if you planned on jumping :).

        Anyways, I’ve really enjoyed out discussion and thank you for engaging with me. Feel free to have the last word if you so desire.

      • Nathan says:

        Dr. Allen,

        Thank you for the engagement as well, I have really appreciated it. I definitely agree that a critical lens is needed to assess the use, value, worth, and applicability of research.

        I just want to end with a little critique on the appendicitis/parachute argument, primarily to more flesh it out for my owns sake. While I know you intended it more tongue and cheek than anything else, I have heard it invoked to disregard quality research more outright.

        Obviously the ethics of placebo-controlled study assessing the efficacy of parachutes in reducing death are out of the question. There are very reasonable proxy studies that can and have been done on identifying the the amount of force the ground exerts on a human sided body when hitting the ground from various heights, studies that show the extent of force people can experience without trauma/death, series of advances in physics that developed in parachute technology in the first place, as well as pretty conclusive observational data observing that people who fall/jump from high altitude are very likely to die, so adding a parachute (regardless of its efficacy) is not likely to lead to a worse outcome (death is already likely). So for parachutes, the development of Newtonian theory (while not technically an accurate theory for universal laws, it can explain a great deal of what we experience here on Earth), technology based on scientific studies testing hypotheses of those theories (all of the science done on flight, motion, materials science, etc), and evaluation of parachute effect and (while not science, observational data noticing people who use parachutes live when they jump/fall a great deal more than people who don’t), I think adds together for convincing evidence of parachute effectiveness in reducing death from high altitude falls.

        This follows pretty normative scientific inquiry to make cases for causality/effect. It starts with an explanatory theory, the conduct of experiments that test hypotheses that attempt to falsify that theory, data from those both experiments refines that theory an leads to applied advances, and then applied advances are evaluated in naturalistic settings.

        Appendicitis treatment works somewhat similarly due to ethical constraints, combining applicable knowledge from accumulated scientific knowledge based on strong theories of biology and observational data that people who have untreated appendicitis tend to die with no intervention. I do believe it possible however to potentially develop alternative treatment for appendicitis that does not involve removing an appendix based on new experimental data in biomedical sciences founded on strong theories of biology.

        This does not happen in many aspects of psychiatric interventions. Theories of mind/health have not been all that explanatory. I think a analytic theory seems to be the most comprehensive (and contradictory and convoluted), but too much of it is not falsifiable to design useful experiments or internally coherent, making its development/refinement more ideological/philosophical than data driven. This isn’t necessarily a bad thing, it’s just not science. While psychotherapy outcomes can be evaluated, the experiments needed to determine efficacy (that certain theoretical models are explanatory for particular phenomena and can be used to predict effect out an intervention) just can’t happen.

        Psychopharmacology is similar. Theories of mind/brain/behavior have yet to be widely explanatory. Less grand theories, like the serotonin imbalance theory of depression, can be tested pretty well, and we have found that is does not hold up. (This may be because of the weak validity of our concept of depression, but that just adds to the point that the theoretical frameworks imagined have not been of much use.) This leads to statements from drug companies that go like “while we don’t know how this medication works, we believe it may work be affecting serotonin systems, which are believed by psychiatrists to play a role in depression.” Statements like these show that the theoretical framework is misunderstood, and because of that, efficacy cannot actually be well determined and hasn’t been. Double-blind studies do not show much drug effect and that effect cannot be attributed to the proposed mechanism of the drug even when it does. What can and is done are outcome studies, assessing overall effect, but again, because it is not based on theory and efficacy has not been shown, all sorts of factors can be affecting how medications “work” or “disorders” are conceptualized/diagnosed that could be very different than what actually is happening. Same with psychotherapies, you can evaluate if people get better when engaging in a treatment, but you cannot make a lot of claims about the specific effects of treatment of use these outcomes to refine theory. This is why Kirsch’s “placebo theory” is getting traction. Evidence of other proposed mechanisms of effect besides the ones proposed can also be found in the data when the theory underpinning the process is underdeveloped.

        People do experience a lot of suffering, distress, and impairment and are willing to seek help for such experiences. Lots of treatments are already offered by people who want to help alleviate that suffering. I do think it important then, at very least, we evaluate outcomes of treatments well, to make sure that people to engage in them to get better in at least intended ways and ways that are not overly risky and to keep people from being exposed to potentially harmful treatments, and to make better decisions about how to helpfully and efficiently diagnose and treat. This means we have to make decisions based on data showing how a treatment has effected other people, and are not all that person specific. It’s the best predictions we can make though. Ideally treatment design would be theory driven, but our theories have been underwhelming. Ideally mechanisms of treatment effect could be determined experimentally, but our lack of theory and tools to control don’t allow that to happen. The best we can do is start at the outcome phase, but also be really humble about what we actually know. Perhaps with more observational data and development/synthesis of social, neurobiological, psychological, philosophical or whatever theories could lead to new avenues of inquiry, but until then, we have to stick with the research that we have and can have, and make sure data are gathered in rigorous studies and treatments are consistently evaluated in applied settings.

    • mara says:

      “A patient who appears to be manic may actually be under the influence of cocaine, to cite an overly obvious example.”

      That reminds of Robert Downey Jr. Got this from his wiki page:

      “Downey flatly denied being “depressed or manic” and that previous attempts to diagnose him with any kind of psychiatric or mood disorder have always been skewed because “the guy I was seeing didn’t know I was smokin’ crack in his bathroom. You can’t make a diagnosis until somebody’s sober.”‘

      I don’t know if that is true. But he’s always listed as a famous person with bipolar disorder, but he denies that he has it.

      • Nathan,

        I think if you take a look at my blog you’ll see we are basically in agreement about diagnostic inflation, over-diagnosing, and inappropriate use of medication. That’s why I don’t think the changes suggested for the DSM are good – they will make an already big problem even worse.

        On the other hand – how do I determine if grief has indeed turned into depression? Well of course there’s no fool-proof way, but there are a lot of questions patients need to be asked – complete with follow-up questions to see if the patient understood the original questions – whose answers offer clues.

        Regardless of the validity of the diagnosis, there are certain clusters of symptoms in certain contexts which tend to respond to anti-depressants and others that do not. The doctor’s experience with the drugs in a wide variety of patients in a wide variety of clinical populations, and with closely following those patients, can make a big difference.

        Melancholic symptoms, highly pervasive vegetative symptoms, inability to come out of the grieving for even a few minutes no matter what, certainly the delusions and hallucinations of a psychotic depression – there are a whole lot of factors which can clue a good doctor in to when meds should be tried and when patients’ symptoms should be labeled as completely normal and the patient sent home.

        Side effects are a big non-issue. I warn the patient about what side effects may occur, and tell them to call me if they seem to be having ANY adverse reactions. If it’s something significant or that can’t be managed with changes in dosage or scheduling, I take them off the drug. The risk is vanishingly small with anti-depressants when this is done, and far smaller than the risk of continuing to have depressive symptoms that might be treatable.

        Studies of antidepressants in the last twenty years can be summarized by the phrase, “garbage in – garbage out. The studies have become a mish-mash of different diagnoses, lack of specificity re target symptoms, vague outcome measures, lack of comprehensive initial assessments of subjects, subjects using other medications, lack of close follow up, and heaven knows what else. Both researchers and patients alike are literally paid to find symptoms where none exist. I’ll take my 38 years of experience prescribing the drugs over the studies any day. And we used to be able to keep subjects in the hospital long enough that we could see what happens under 24 hour observation. Most of today’s psychiatrists have not seen this, so they don’t really know!

  9. Altostrata says:

    Ronald Pies also makes the tautological argument that doctors who know what they’re doing won’t make mistakes based on misinterpretation of the DSM-5.

    However, we have some empirical evidence that there are a great number of doctors who don’t know what they’re doing with psychiatric diagnosis or treatment. According to an October 2011 CDC report http://www.cdc.gov/nchs/data/databriefs/db76.htm , 11% of the US population over the age of 12 is taking antidepressants. This is about 30 million people. Only a third of those with MDD are taking antidepressants, approximately 6 million, leaving 24 million with a non-MDD diagnosis being medicated with drugs found effective only for MDD.

    “More than 60% of Americans taking antidepressant medication have taken it for 2 years or longer, with 14% having taken the medication for 10 years or more.

    ….Less than one-third of Americans taking one antidepressant medication and less than one-half of those taking multiple antidepressants have seen a mental health professional in the past year.

    ….From 1988–1994 through 2005–2008, the rate of antidepressant use in the United States among all ages increased nearly 400%.”

    Here we have a great deal of unmonitored antidepressant usage. In August 2011, a paper by Mojtabai et al http://www.internalmedicinenews.com/index.php?id=495&cHash=071010&tx_ttnews%5Btt_news%5D=62054 found 80% of antidepressant prescribing was done by primary care doctors, often with no psychiatric diagnosis at all.

    Some large number of doctors don’t know what they’re doing in prescribing antidepressants. If it’s not psychiatrists who are doing all the clueless prescribing, it must be the other doctors.

    Maybe they’re not making mistakes based on misintepretation of the DSM-IV, but in the interest of public health, we have to ask the question “What is the DSM-5 (and by extension, organized psychiatry) doing to remedy this situation?”

    Obviously, nothing. The DSM-5 generates even more shoddy diagnoses for sloppy clinicians to misinterpret. It’s even moving toward a checklist format — so easy even amateurs (or machines) can make psychiatric diagnosis!

    As David Healy trenchantly observed in a recent blog post http://davidhealy.org/notes-on-a-scandal, organized psychiatry may be engaged in professional suicide, specifically by auto-asphyxiation while self-pleasuring — as its hubris over the DSM-5 confirms.

    • Nathan says:

      Alto,

      Though I think we don’t entirely agree about everything, I appreciate you framing the issue as a tautology. I think that is really helpful. Psychiatric diagnoses are defined or at least greatly guided by the DSM, but somehow good diagnosing will avoid the pitfalls of the DSM. How does one diagnose well psychiatric disorders (which have limited validity) without reference to the diagnostic manual? Ultimately, the DSM shapes how diagnoses happen.

  10. Tom says:

    There are good reasons why the popular press refers to DSM as not a book, but a bible– Psychiatry’s Bible. Let’s face it. When the DSM study committees convene, they are doing nothing more than having a modern day version of the Council of Trent, where Christendom convened to vote on all sorts of matters related to Church doctrine, including what gospels (aka diagnoses) were to be included in the Bible and even whether Jesus (aka medications) was (were) the Messiah (Messiahs)! The DSM is most certainly NOT a scientific document. It is a financial-political document, bought and paid for by Big Pharma and its swarthy surrogates (aka psychiatrists who have made Faustian bargains with the drug companies to enrich themselves, and the patient be damned). Kind of like what Goldman-Sachs is doing with their “muppets” in the financial world.

  11. Altostrata says:

    1boringoldman sums up what’s wrong with the DSM-5 here http://1boringoldman.com/index.php/2012/03/16/to-pick-up-the-task/ . It’s not the old, inert look-up book. It’s a manifesto.

    (Tom, I agree with your likening of organized psychiatry to the Church.)

    • stevebMD says:

      Thank you for the link. It is a powerful argument against the “medicalization” of grief, and eloquently sheds light on the uniqueness of each individual’s response to a traumatic or unexpected loss. That uniqueness is something we ought to embrace, to help each person recover in his or her own way. It is likely that most mental health clinicians agree with that concept, but I agree with you (and others here) that, in practice, what’s written in the DSM will ultimately guide (and homogenize) treatment, and that is unfortunate.

      Thanks also for the correction. The loss of an 8-month old fetus is a stillbirth and not a miscarriage. The text has been changed.

      • SuiGeneris says:

        Thank you very much for reading and for your reply. I also thank you for correcting the text. I hope you don’t mind one more comment, from a humanistic perspective, I’d invite you to look, once again, at the photo of “Zach” posted on the link to the blog and ask yourself if he is, in fact, a baby or a “fetus”. Terminology which we use as providers of health and medical care can be very important to the ways in which we interact with and respect the experiences of others. I’ve never been to a “fetus shower” and most people don’t walk up to an obviously pregnant woman and ask her, “When is your fetus is due?” For a mother, her baby died. Using devaluing language often further exacerbates shame and disenfranchisement of women experiencing these losses (and this is why language is important to other marginalized populations such as LGBTQ). And being a psychiatrist, you surely understand the devastating consequences of shame and guilt.

        I do, very much, appreciate your reply and your willingness to discuss.

        Respectfully.

      • stevebMD says:

        If you’ve read my other posts (or if you’ve worked with me as a colleague or as a patient/client/consumer– take your choice of words), you will know that I bend over backwards to make those that I serve feel welcome and respected. I would never use the word “fetus” with a patient, a friend, my wife, etc. It is, as you point out, a technical term. I used it because (a) I believed I was responding to a fellow health-care professional, and (b) to say “loss of an 8-month old baby” would be misleading and incorrect in an entirely different way.

        While I appreciate your input– and absolutely agree that the words we use have great impact on our patients (see my posts on “disability”)– I don’t want to be sidetracked from the main message re: grief/bereavement, on which you and I seem to be in agreement.

        One final thing: “…being a psychiatrist, you surely understand the devastating consequences of shame and guilt.”

        No. I understand the consequences of shame and guilt by being a person who has experienced them. NOT by virtue of my being a psychiatrist. Big difference.

      • SuiGeneris says:

        stevebMD – I appreciate the clarification and very, very well said on the final sentence. Indeed, do we all. Like death, shame touches everyone, save the few. I considered that you may have been speaking to a general provider audience but because this is a public forum and women affected by this type of loss may read it (there is quite abuzz about this DSM/grief debate). The death of anyone who is Beloved to us, whether the death of a baby at 8-mos gestation or the death of an elder parent or a partner- can unhinge us and call into question our world assumptions (Janoff-Bulman). Thank you for this enlightening discussion.

    • Carolyn Thomas says:

      Thank you SuiGeneris for the link to this profoundly moving post. It is a “must-read” for all who hold the power of the prescription pad in their hands.

      The sadness and grief she describes (specifically about a parent’s loss of a child, but also applicable to other forms of far less devastating losses as well) is important to honour and respect.

      For example, according to Mayo Clinic cardiologists, up to 65% of heart attack survivors suffer severe depression, yet fewer than 10% are appropriately identified. Having been one of the 65% post-MI, I can vouch for the devastating despair and debilitation I lived through. Yet recently, when I came across Sandra Pawula’s essay comparing depression with old fashioned “sadness” – I immediately wondered if the semantics espoused by Big Pharma (and the resultant Medicalization of All Things) may be overlooking sadness as a predictable and valid reaction to suddenly having your entire world turned upside down (as surviving a catastrophic illness can do to any formerly healthy person).

      More on this at: “Is It Post-Heart Attack Depression – Or Just Feeling Sad?” http://myheartsisters.org/2011/07/24/is-it-post-heart-attack-depression-or-just-feeling-sad/

      • SuiGeneris says:

        Indeed, thank you Carolyn. I will read the article and thank you for your reply.

      • Altostrata says:

        Carolyn — Exactly! Mortality knocks on the door and you are forced to a huge life change — is it not normal to feel sad and apprehensive? This is one of the areas where a diagnosis of “depression” has proliferated, along with reflexive prescription of an antidepressant.

        A friend was recently in a convalescent facility after a botched angioplasty. A psychiatrist wandered in and, without lifting his eyes from his chart, said “You’ve had a heart attack, you’re depressed, I’m going to prescribe an antidepressant.”

        We were aghast at this careless prescribing. She was already taking 7 drugs for her medical condition. While incensed by the surgical error that incurred months of convalescence, she insisted she wasn’t depressed.

        If you’re not careful, you’re automatically going to get an antidepressant added to your regimen after a heart attack.

    • SuiGeneris says:

      Carolyn,
      That was an excellent blog and I will share it!

      Thank you!

  12. AA says:

    Hypothetical situation – Parents lose 4 kids in a house fire who tragically perish. What would be considered an abnormal grief reaction?

    • SuiGeneris says:

      AA- my response to that is posted in the blog link above. Please do visit and read. What would be considered abnormal? Losing four children in a house fire. The parents reaction to that, whatever that may, in my humble opinion, cannot possibly be judge as pathological by others.

      • AA says:

        SuiGeneris,

        Thanks, which blog link as I see more than one? Totally agree with you about the parent’s reaction whatever it is, shouldn’t be charged as pathological. But sadly, that is exactly what would happen.

    • SuiGeneris says:

      http://www.drjoanne.blogspot.com – loved your comment btw.

  13. Anonymouus says:

    This has clearly been an illuminating post and any doctor (clinician – whatever) needs to bring all of their wisdom, experience, continuing education and acumen – not to mention their humanity to the table. I think humility goes a long way too. I guess my only beef is, even given the monstrous hurdles, psychiatrists need to huddle together to get some respect and I just do not see that happening any time soon. I have witnessed this even in distinguished hospitals, when there is need for a “consult” on someone really “out of it”, before a little recognition is given. Then all of a sudden, your peers, in other specialties, can not be too thankful! It is hard enough to be a doctor, have a family or personal life, but as learned professionals, stand up and do not be dictated to by industries that are only in it for their own bacon. As always Dr. Steve, you are a very thoughtul person and there was some heartbreaking banter in some of the other’s refelctions. Real mental illness is not so hard to recognize and everyone posting here is aware of that. Best.

  14. Duane Sherry says:

    Dr. Balt,

    I think it’s time to stop labeling people altogether.
    These psychiatric diagnoses (labels) may have some initial appeal to those who are searching for answers about their own (or someone elses behavior), but they are much like psychiatric drugs – they cause more harm than good for the vast majority.

    Paula Caplan, Ph.D. has some thoughts on the subject –

    http://www.psychdiagnosis.net/psychiatric_stories.html#Anchor-48213

    Also, I think its time to get rid of the term “schizophrenia”… It’s dehumanizing. The International Society recently decided to do so –

    http://blog.humangivens.com/2012/03/international-society-removes.html

    Duane

  15. mara says:

    Steve,

    I was talking to a friend online and she typed something that reminded me of you and some of your posts. She said I can repost. Just can’t use her name:

    “well I told my doctor that I am fully capable of focusing and studying at night, but during the day I can’t study worth shit”

    “he said that’s an adult form of ADD due to years of habitually studying at night from college”

    “and he gave me this so I can study during the day…”

  16. Peter Parry says:

    I recently read “The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder.” by Horwitz and Wakefield. The foreword was by Robert Spitzer, the chair of the DSM-III task force.

    Spitzer said how he’d revised his position over time and realised that psychiatry in general was neglecting contextual factors. He noted that the introductions to the DSM manuals (DSM-III, IIIR and IV)state that diagnoses are “atheoretical” with regard to etiology and discuss the need to consider contextual stressors and not to use the manual in a “cookbook” fashion.

    But Spitzer in his foreword now says the problem is that this information is not in the criteria boxes (i.e. the little boxes in DSM with the checklists of symptoms/signs). The criteria boxes being the only thing that most people ever read…

    Thus my thinking is that something like a “black box” FDA warning should be inserted at the start of each of the DSM criteria boxes, e.g.:

    Criterion A: This diagnosis of (MDD/GAD/ODD/Panic disorder etc) is atheoretical with regards to aetiology. Different factors may be causative in any particular individual. Also any individual whose symptoms meet criteria B through to (D/E/F/G etc) needs to be considered in the context of their life history and stressors from a biopsychosociocultural perspective. Simply meeting criteria B through to (D/E/F/G etc) does not necessarily indicate disorder or pathology, contextual factors need to be considered by the clinician/researcher making the diagnosis.

    As Dr Carlat notes the “good clinician” does this anyway. But problem is parents, teachers, lawyers, health insurers, pharma execs marketing managers and sales reps, health bureaucrats, non-psychiatrist and non-psychologist clinicians and too many psychiatrist and psychologists themselves – don’t. Commonly diagnostic labels are reified to discrete neuropathological entities and the next question is “which pill?”

    An “A” criteria as above staring one in the face seems needed and could be the best change DSM-5 could introduce.

    I have a relevant article that’s not a hard read – https://www.mja.com.au/sites/default/files/issues/191_11_071209/par10719_fm.pdf

    • Altostrata says:

      The good clinician! The good clinician! Everyone in medicine talks about the good clinician as if he or she was the norm.

      From the patient’s point of view, the good clinician who prescribes psychiatric drugs sparingly in a rational way with patient safety the first concern is very, very rare.

      You doctors, who may be good clinicians yourselves, don’t have the faintest idea of how bad it is out there. At best, you are generalizing from your own singular case and being extremely generous to your colleagues, including the primary care doctors who are merely dabbling in psychiatric treatment.

      The situation is beyond appalling. In the not too distant future, the promiscuous prescribing of psychiatric drugs — let’s face it, perpetrated by clinicians who ALL think of themselves as “good doctors” — is going to show up in public health statistics in a big way.

      • AA says:

        Alto,

        Your post is right on target.

        Recently, I went to a non psychiatric doctor who totally misinterpreted my frustrations with current treatment that wasn’t going well as a biological mental illness. It was quite frightening to be honest.

        As a result, I feel reluctant to see another doctor even though I never received help for what I went to see this physician for.

        I am making some progress in solving the problem on my own thanks to an “evil” internet board but that sure doesn’t say much for the state of modern medicine.

  17. Nathan says:

    Adding the extra criteria shouldn’t be necessary, but I do agree that doing so would be a simple and effective way to hammer the message in especially to non-mental health professionals. Also, the DSM would be a bigger book, and the APA could sell it for a higher price. Seems like good starting point for a win-win situation.

    I still get uncomfortable with how clinicians make judgements of pathology/disorder. Clinicians are not very consistent with factoring similar information with different patients, the disorders lack validity, and there is can be quite a bit of bias for all sorts of reasons. I suppose it wouldn’t be any worse than it is now, and the new criteria would perhaps at least force clinicians to slow down the diagnosing process and perhaps have to make a more detailed case for why particular symptoms in a particular contexts for a particular patient can be considered pathology (when perhaps it wouldn’t be for a similar patient in a similar situation with a similar past.) Yes, the added criteria would I believe limit over-diagnosing and force clinicians to more intentionally interrogate their own judgments and decisions, and provide some more information/reasoning to make a case for pathology beside “I just feel it.”

  18. mara says:

    @altostrata: I don’t even think they have to buy it from their friends anymore. It’s pretty easy to get a prescription. All of my friends who used stimulants had a prescription from either a psychiatrist or GP. It’s actually kinda shocking. I have an older friend with a grown son. When he went to college, he reported to his GP that he had a lot of trouble focusing on studying. He was then diagnosed with ADHD. So she gave him some “focus pills” that he could take “as needed” in order to study. I told my friend that I had never heard of such a thing (a stimulant prescribed as needed for ADHD). But she just gave me a look and told me that sounded unhealthy to have to take it all the time. She also asked me why he should have to take it every day when he only had to focus when it was time to study. I was at a loss for words. I had no clue how to respond. I guess I could have said, “Usually, people with ADHD need to be medicated often because they can’t focus on conversations with friends, work, taking out the trash, driving, school, etc…it’s not just about having trouble studying. If his only impairment is studying for final exams, I don’t know that stimulants are appropriate.” But I didn’t tell her that because I didn’t wanna make waves.

  19. Helpful information. Lucky me I found your website by accident, and I am shocked why this twist of fate didn’t took place earlier! I bookmarked it.

  20. Steve ,

    Yes , the context is still a difference. Seems to be manic patients who may actually be under the influence of cocaine , give an overly obvious example . But I was surprised at labels I’ve seen a psychiatrist to know the number of patients they had taken cocaine is bipolar . Social and psychological aspects , but also pervasiveness and duration of symptoms . There is a large family after the fight anger attacks manic person can look at , but only for a short time . That’s what I said .

    Nathan ,

    You’re right that the average person has no way of knowing who is a good doctor, who is not. I was in medical school, my father in law was told to get a whirlpool therapy “muscle spasm ” when I can tell him there within five minutes, phlebitis , because his legs are hot . I sent him to the hospital , they admitted him. If he had had massage treatment, he could easily have pulmonary embolism and death !

    I do not know what we can do bad doctor. The average patient has just been processed in advance and a whirlpool .

    In addition, some diagnosis is very cultural constraints ( borderline personality disorder ) , while others much less. The content is often paranoid schizophrenia is about the FBI or the CIA ‘s delusion. If someone lives in India, which is obviously some other organizations . However, this is a very small difference.

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