My Own Bipolar Kerfuffle

August 5, 2012

I have a confession to make.  I don’t know what “bipolar disorder” is.  And as a psychiatrist, I’ll admit that’s sort of embarrassing.

Okay, maybe I’m exaggerating when I say that I don’t know what bipolar disorder is.  Actually, if you asked me to define it, I’d give you an answer that would probably sound pretty accurate.  I’ve read the DSM-IV, had years of training, took my Boards, treated people in the midst of manic episodes, and so on.  The problem for me is not the “idea” of bipolar disorder.  It’s what we mean when we use that term.

I recognized this problem only recently—in fact, just last month, as I was putting together the July/August issue of the Carlat Psychiatry Report (now available to subscribers here).  This month’s issue is devoted to the topic of “Bipolar Disorder,” and two contributors, faculty members at prestigious psychiatry departments, made contradictory—yet perfectly valid—observations.  One argued that it’s overdiagnosed; the other advocated for broadening our definition of bipolar disorder—in particular, “bipolar depression.”  The discrepancy was also noted in several comments from our Editorial Board.

Disagreements in science and medicine aren’t necessarily a bad thing.  In fact, when two authorities interpret a phenomenon differently, it creates the opportunity for further experimentation and investigation.  In time, the “truth” can be uncovered.  But in this case, as with much in psychiatry, “truth” seems to depend on whom you ask.

Consider this question.  What exactly is “bipolar depression”?  It seems quite simple:  it’s when a person with bipolar disorder experiences a depressive episode.  But what about when a person comes in with depression but has not had a manic episode or been diagnosed with bipolar disorder?  How about when a person with depression becomes “manic” after taking an antidepressant?  Could those be bipolar depression, too?  I suppose so.  But who says so?  One set of criteria was introduced by Jules Angst, a researcher in Switzerland, and was featured prominently in the BRIDGE study, published in 2011.  His criteria for bipolarity include agitation, irritability, hypomanic symptoms for as short as one day, and a family history of mania.  Other experts argue for a “spectrum” of bipolar illness.

(For a critique of the BRIDGE study, see this letter to the editor of the Archives of General Psychiatry, and this detailed—and entertaining—account in David Allen’s blog.)

The end result is rather shocking, when you think about it:  here we have this phenomenon called “bipolar disorder,” which may affect 4% of all Americans, and different experts define it differently.  With the right tweaking, nearly anyone who comes to the attention of a psychiatrist could be considered to have some features suggestive of someone’s definition of bipolar disorder.  (Think I’m kidding?  Check out the questionnaire in the appendix of Angst’s 2003 article.)

Such differences of opinion lead to some absurd situations, particularly when someone is asked to speak authoritatively about this disorder.  At this year’s APA Annual Meeting for example, David Kupfer (DSM-IV Task Force Chair) gave a keynote address on “Rethinking Bipolar Disorder,” which included recommendations for screening adolescents and the use of preventive measures (including drugs) to prevent early stages of the illness.  Why was it absurd?  Because as Kupfer spoke confidently about this disease entity, I looked around the packed auditorium and realized that each person may very well have has his or her own definition of bipolar disorder.  But did anyone say anything?  No, we all nodded in agreement, deferring to the expert.

This problem exists throughout psychiatry.  The criteria for each diagnosis in the DSM-IV can easily be applied in a very general way.  This is due partly to fatigue, partly to the fact that insurance companies require that we give a diagnosis as early as the first visit, partly because we’re so reluctant (even when it’s appropriate) to tell patients that they’re actually healthy and may not even have a diagnosis, and partly because different factions of psychiatrists use their experience to create their own criteria.  It’s no wonder that as criteria are loosened, diagnoses are misapplied, and the ranks of the “mentally ill” continue to grow.

As editor of a newsletter, I’m faced with another challenge I didn’t quite expect.  I can’t come out and say that bipolar disorder doesn’t exist (which wouldn’t be true anyway—I have actually seen cases of “classic,” textbook-style mania which do respond to medications as our guidelines would predict).  But I also can’t say that several definitions of “bipolar” exist.  That may be perceived as being too equivocal for a respectable publication and, as a result, some readers may have difficulty taking me seriously.

At the risk of sounding grandiose, I may be experiencing what our field’s leadership must experience on a regular basis.  Academic psychiatrists make their living by conducting research, publishing their findings, and, in most cases, specializing in a given clinical area.  It’s in their best interest to assume that the subjects of their research actually exist.  Furthermore, when experts see patients, they do so in a specialty clinic or clinical trial, which reinforces their definitions of disease.

This can become a problem to those of us seeing the complicated “real world” patients on the front lines, especially when we look to the experts for answers to such questions as whether we should use antipsychotics to treat acute mania, or whether antidepressants are helpful for bipolar depression.  If their interpretations of the diagnoses simply don’t pertain to the people in our offices, all bets are off.  Yet this, I fear, is what happens in psychiatry every day.

In the end, I can’t say whether my definition of bipolar disorder is right or not, because even the experts can’t seem to agree on what it is.  As for the newsletter, we decided to publish both articles, in the interest of maintaining a dialogue.  Readers will simply have to use their own definition of “bipolar disorder” and “bipolar depression” (or eschew them altogether)—hopefully in ways that help their patients.  But it has been an eye-opening experience in the futility (and humility) of trying to speak with authority about something we’re still trying desperately to understand.

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The Well Person

March 21, 2012

What does it mean to be “normal”?  We’re all unique, aren’t we?  We differ from each other in so many ways.  So what does it mean to say someone is “normal,” while someone else has a “disorder”?

This is, of course, the age-old question of psychiatric diagnosis.  The authors of the DSM-5, in fact, are grappling with this very question right now.  Take grieving, for example.  As I and others have written, grieving is “normal,” although its duration and intensity vary from person to person.  At some point, a line may be crossed, beyond which a person’s grief is no longer adaptive but dangerous.  Where that line falls, however, cannot be determined by a book or by a committee.

Psychiatrists ought to know who’s healthy and who’s not.  After all, we call ourselves experts in “mental health,” don’t we?  Surprisingly, I don’t think we’re very good at this.  We are acutely sensitive to disorder but have trouble identifying wellness.  We can recognize patients’ difficulties in dealing with other people but are hard-pressed to describe healthy interpersonal skills.  We admit that someone might be able to live with auditory hallucinations but we still feel an urge to increase the antipsychotic dose when a patient says she still hears “those voices.”   We are quick to point out how a patient’s alcohol or marijuana use might be a problem, but we can’t describe how he might use these substances in moderation.  I could go on and on.

Part of the reason for this might lie in how we’re trained.  In medical school we learn basic psychopathology and drug mechanisms (and, by the way, there are no drugs whose mechanism “maintains normality”—they all fix something that’s broken).  We learn how to do a mental status exam, complete with full descriptions of the behavior of manic, psychotic, depressed, and anxious people—but not “normals.”  Then, in our postgraduate training, our early years are spent with the most ill patients—those in hospitals, locked facilities, or emergency settings.  It’s not until much later in one’s training that a psychiatrist gets to see relatively more functional individuals in an office or clinic.  But by that time, we’re already tuned in to deficits and symptoms, and not to personal strengths, abilities, or resilience-promoting factors.

In a recent discussion with a colleague about how psychiatrists might best serve a large population of patients (e.g., in a “medical home” model), I suggested  that perhaps each psychiatrist could be responsible for a handful of people (say, 300 or 400 individuals).  Our job would be to see each of these 300-400 people at least once in a year, regardless of whether they have psychiatric diagnosis or not.  Those who have emotional or psychiatric complaints or who have a clear mental illness could be seen more frequently; the others would get their annual checkup and their clean bill of (mental) health.  It would be sort of like your annual medical visit or a “well-baby visit” in pediatrics:  a way for a person to be seen by a doctor, implement preventive measures,  and undergo screening to make sure no significant problems go unaddressed.

Alas, this would never fly in psychiatry.  Why not?  Because we’re too accustomed to seeing illness.  We’re too quick to interpret “sadness” as “depression”; to interpret “anxiety” or “nerves” as a cue for a benzodiazepine prescription; or to interpret “inattention” or poor work/school performance as ADHD.  I’ve even experienced this myself.  It is difficult to tell a person “you’re really doing just fine; there’s no need for you to see me, but if you want to come back, just call.”  For one thing, in many settings, I wouldn’t get paid for the visit if I said this.  But another concern, of course, is the fear of missing something:  Maybe this person really is bipolar [or whatever] and if I don’t keep seeing him, there will be a bad outcome and I’ll be responsible.

There’s also the fact that psychiatry is not a primary care specialty:  insurance plans don’t pay for an annual “well-person visit” with the a psychiatrist.  Patients who come to a psychiatrist’s office are usually there for a reason.  Maybe the patient deliberately sought out the psychiatrist to ask for help.  Maybe their primary care provider saw something wrong and wanted the psychiatrist’s input.  In the former, telling the person he or she is “okay” risks losing their trust (“but I just know something’s wrong, doc!“).  In the latter, it risks losing a referral source or professional relationship.

So how do we fix this?  I think we psychiatrists need to spend more time learning what “normal” really is.  There are no classes or textbooks on “Normal Adults.”  For starters, we can remind ourselves that the “normal” people around whom we’ve been living our lives may in fact have features that we might otherwise see as a disorder.  Learning to accept these quirks, foibles, and idiosyncrasies may help us to accept them in our patients.

In terms of using the DSM, we need to become more willing to use the V71.09 code, which means, essentially, “No diagnosis or condition.”  Many psychiatrists don’t even know this code exists.  Instead, we give “NOS” diagnoses (“not otherwise specified”) or “rule-outs,” which eventually become de facto diagnoses because we never actually take the time to rule them out!  A V71.09 should be seen as a perfectly valid (and reimbursable) diagnosis—a statement that a person has, in fact, a clean bill of mental health.  Now we just need to figure out what that means.

It is said that when Pope Julius II asked Michelangelo how he sculpted David out of a marble slab, he replied: “I just removed the parts that weren’t David.”  In psychiatry, we spend too much time thinking about what’s not David and relentlessly chipping away.  We spend too little time thinking about the healthy figure that may already be standing right in front of our eyes.


Is The Criticism of DSM-5 Misguided? Part II

March 14, 2012

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.


Disruptive Technology Vs. The Disruptive Physician

February 26, 2012

The technological advances of just the last decade—mobile computing, social networking, blogging, tablet computers—were never thought to be “essential” when first introduced.  But while they started as novelties, their advantages became apparent, and today these are all part of our daily lives.  These are commonly referred to as “disruptive technologies”:  upstart developments that originally found their place in niche markets outside of the mainstream, but gradually “disrupted” the conventional landscape (and conventional wisdom) to become the established ways of doing things.

In our capitalist economy, disruptive technology is considered a very good thing.  It has made our lives easier, more enjoyable, and more productive.  It has created no small number of multimillionaires.  Entrepreneurs worldwide are constantly looking for the next established technologies to disrupt, usurp, and overturn, in hopes of a very handsome payoff.

In medicine, when we talk about “disruption,” the implication is not quite as positive.  In fact, the term “disruptive physician” is an insult, a black mark on one’s record that can be very hard to overcome.  It refers to someone who doesn’t cooperate, doesn’t follow established protocols, yells at people, discriminates against others, who might abuse drugs or alcohol, or who is generally incompetent.  These are not good things.

Really?  Now, no one would argue that substance abuse, profanity, spreading rumors, degrading one’s peers, or incompetence are good.  But what about the physician who “expresses political views that are disagreeable to the hospital administration”?  How about the physician who speaks out about deficiencies in patient care or patient safety, or who (legitimately) points out the incompetence of others?  How about the physician who prioritizes his own financial and/or business objectives over those of the hospital (when in fact it may be the only way to protect one’s ability to practice)?  All of these have been considered to be “disruptive” behaviors and could be used by highly conservative medical staffs to discipline physicians and preserve the status quo.

Is this fair?  In modern psychiatry, with its shrinking appointment lengths, overreliance on the highly deficient DSM, excessive emphasis on pharmacological solutions, and an increasing ignorance of developmental models and psychosocial interventions among practitioners, maybe someone should stand up and express opinions that the “powers that be” might consider unacceptable.  Someone should speak out on behalf of patient safety.  Someone should point out extravagant examples of waste, incompetence, or abuse of privilege.  Plenty of psych bloggers and a few renegade psychiatrists do express these opinions, but they (we?) are a minority.  I don’t know of any department chairmen or APA officers who are willing to be so “disruptive.”  As a result, we’re stuck with what we’ve got.

That’s not to say there aren’t any disruptive technologies in psychiatry.  What are they?  Well, medications, for instance.  Drug treatment “disrupted” psychoanalysis and psychotherapy, and represent the foundation of most psychiatric treatment today.  Over the last 30 years, pharmaceutical companies (and prescribers) have earned millions of dollars from SSRIs, SNRIs, second-generation antipsychotics, psychostimulants, and many others.  But are people less mentally ill now than they were in the early 1980s?  Today—just in time for patent expirations!—we’re already seeing the next disruptive medication technologies, like those based on glutamate and glutamine signaling.  According to Stephen Stahl at the most recent NEI Global Congress, “we’ve beaten the monoamine horse sixteen ways to Sunday” (translation: we’ve milked everything we can out of the serotonin and dopamine stories) and glutamate is the next blockbuster drug target to disrupt the marketplace.

Another disruptive technology is the DSM.  I don’t have much to add to what’s already been written about the DSM-5 controversy except to point out what should be obvious:  We don’t need another DSM right now.  Practically speaking, a new DSM is absolutely unnecessary.  It will NOT help me treat patients any better.  But it’s coming, like it or not.  It will disrupt the way we have conducted our practices for the last 10 years (guided by the equally imperfect DSM-IV-TR), and it will put millions more dollars in the coffers of the APA.

And then, of course, is the electronic medical record (EMR).  As with the DSM-5, I don’t need to have an EMR to practice psychiatry.  But some politicians in Washington, DC, decided that, as a component of the Affordable Care Act (and in preparation for truly nationalized health care), we should all use EMRs.  They even offered a financial incentive to doctors to do so (and are levying penalties for not doing so).  And despite some isolated benefits (which are more theoretical than practical, frankly), EMRs are disruptive.  Just not in the right way.  They disrupt work flow, the doctor-patient relationship, and, sometimes, common sense.  But they’re here to stay.

Advances in records & database management, in general, are the new disruptive technologies in medicine.  Practice Fusion, a popular (and ad-supported) EMR has earned tens of millions of dollars in venture capital funding and employs over 150 people.  And what does it do with the data from the 28 million patients it serves?  It sells it to others, of course.  (And it can tell you fun things like which cities are most “lovesick.”  How’s that for ROI?)

There are many other examples of companies competing for your health-care dollar, whose products are often only peripherally related to patient care but which represent that holy grail of the “disruptive technology.”  There are online appointment scheduling services, telepsychiatry services, educational sites heavily sponsored by drug companies, doctor-only message boards (which sell doctors’ opinions to corporations), drug databases (again, sponsored by drug companies), and others.

In the interest of full disclosure, I use some of the above services, and some are quite useful.  I believe telemedicine, in particular, has great potential.  But at the end of the day, these market-driven novelties ignore some of the bigger, more entrenched problems in medicine, which only practicing docs see.  In my opinion, the factors that would truly help psychiatrists take better care of patients are of a different nature entirely:  improving psychiatric training (of MDs and non-MD prescribers); emphasizing recovery and patient autonomy in our billing and reimbursement policies; eliminating heavily biased pharmaceutical advertising (both to patients and to providers); revealing the extensive and unstated conflicts of interest among our field’s “key opinion leaders”; reforming the “disability” system and disconnecting it from Medicaid, particularly among indigent patients; and reallocating health-care resources more equitably.  But, as a physician, if I were to go to my superiors with any ideas to reform the above in my day-to-day work, I run the risk of being labeled “disruptive.”  When in fact, that would be my exact intent:  to disrupt some of the damaging, wasteful practices that occur in our practices almost every day.

I agree that disruption in medicine can be a good thing, and can advance the quality and cost-effectiveness of care.  But when most of the “disruptions” come from individuals who are not actively in the trenches, and who don’t know where needs are the greatest, we may be doing absolutely nothing to improve care.  Even worse, when we fail to embrace the novel ideas of physicians—but instead discipline those physicians for being “disruptive”—we risk punishing creativity, destroying morale, and fostering a sense of helplessness that, in the end, serves no one.


The Curious Psychology of “Disability”

December 28, 2011

I’ll start this post with a brief clinical vignette:

I have been seeing Frank, a 44 year-old man, on a regular basis for about six months.  He first came to our community clinic with generalized, nonspecific complaints of “anxiety,” feeling “uncomfortable” in public, and getting “angry all the time,” especially toward people who disagreed with him.  His complaints never truly met official criteria for a DSM-IV disorder, but he was clearly dissatisfied with much in his life and he agreed to continue attending biweekly appointments.  Frank once requested Xanax, by name, but I did not prescribe any medication; I never felt it was appropriate for his symptoms, and besides, he responded well to a combined cognitive-interpersonal approach exploring his regret over past activities as a gang member (and related incarcerations), feelings of being a poor father to his four daughters, and efforts to improve his fragile self-esteem.  Even though Frank still has not met criteria for a specific disorder (he currently holds the imprecise and imperfect label of “anxiety NOS”), he has shown significant improvement and a desire to identify and reverse some of his self-defeating behaviors.

Some of the details (including his name) have been changed to preserve Frank’s privacy.  However, I think the general story still gets across:  a man with low self-worth, guilty feelings, and self-denigration from his overidentification with past misdeeds, came to me for help.  We’ve made progress, despite a lack of medications, and the lack of a clear DSM-IV (or, most likely, DSM-5) diagnosis.  Not dramatic, not earth-shattering, but a success nonetheless.  Right?

Not so fast.

Shortly after our appointment last week, I received a request for Frank’s records from the Social Security Administration, along with a letter from a local law firm he hired to help him obtain benefits.  He had apparently applied for SSI disability and the reviewers needed to see my notes.

I should not have been surprised by this request.  After all, our clinic receives several of these requests each day.  In most cases, I don’t do anything; our clinic staff prints out the records, sends them to SSA, and the evaluation process proceeds generally without any further input from us (for a detailed description of the disability evaluation process, see this article).  But for some reason, this particular request was uniquely heartbreaking.  It made me wonder about the impact of the “disability” label on a man like Frank.

Before I go further, let me emphasize that I’m looking at Frank’s case from the viewpoint of a psychiatrist, a doctor, a healer.  I’m aware that Frank’s family is under some significant financial strain—as are many of my patients in this clinic (a topic about which I’ve written before)—and some sort of welfare or financial support, such as SSI disability income, would make his life somewhat easier.  It might even alleviate some of his anxiety.

However, in six months I have already seen a gradual improvement in Frank’s symptoms, an increase in his motivation to recover, and greater compassion for himself and others.  I do not see him as “disabled”; instead, I believe that with a little more effort, he may be able to handle his own affairs with competence, obtain some form of gainful employment, and raise his daughters as a capable father.  He, too, recognizes this and has expressed gratitude for the progress we have made.

There is no way, at this time, for me to know Frank’s motives for applying for disability.  Perhaps he simply saw it as a way to earn some supplementary income.  Perhaps he believes he truly is disabled (although I don’t think he would say this—and if he did, I wish he’d share it with me!).  I also have no evidence to suggest that Frank is trying to “game the system.”  He may be following the suggestions of a family member, a friend, or even another healthcare provider.  All of the above are worthwhile topics to discuss at our next appointment.

But once those records are sent, the evaluation process is out of my hands.  And even if Frank’s request is denied, I wonder about the psychological effect of the “disability” label on Frank’s desire to maintain the gains he has made.  Labels can mean a lot.  Psychiatric diagnoses, for instance, often needlessly and unfairly label people and lead to unnecessary treatment (and it doesn’t look like DSM-5 will offer much improvement).  Likewise, labels like “chronic,” “incurable,” and “disabled” can also have a detrimental impact, a sentiment expressed emphatically in the literature on “recovery” from mental illness.  The recovery movement, in fact, preaches that mental health services should promote self-direction, empowerment, and patient choice.  If, instead, we convey pessimism, hopelessness, and the stigma of “disability,” we may undermine those goals.

As a healer, I believe that my greatest responsibility and most difficult (although most rewarding) task is to instill hope and optimism in my patients.  Even though not all of them will be entirely “symptom-free” and able to function competently in every situation life hands them, and some may require life-long medication and/or psychosocial support (and, perhaps, disability income), I categorically refuse to believe that most are “disabled” in the sense that they will never be able to live productive, satisfying lives.

I would bet that most doctors and most patients agree with me.  With the proper supports and interventions, all patients (or “users” or “consumers,” if you prefer those terms) can have the opportunity to succeed, and potentially extricate themselves from invisible chains of mental illness.  In Frank’s case, he is was almost there.

But the fact that we as a society provide an institution called “disability,” which provides benefits to people with a psychiatric diagnosis, requiring that they see a psychiatrist, and often requiring that they take medication, sends a very powerful—and potentially unhealthy—psychological message to those who can overcome their disability.  To Frank, it directly contradicts the messages of hope and encouragement I try to offer at each visit.  It makes him dependent upon me, rather than upon himself and his own resources and abilities.  In other words, to a man like Frank, disability is anti-recovery.

I don’t have an easy answer to this problem.  For starters, changing the name of “disability” to something like “temporary psychological material support”—a substitute label, nothing more—might be helpful.  Also, rewarding recipients (e.g., not repealing their benefits) for meeting predetermined milestones of recovery (part-time work, independent housing, etc) may also help.  But the more I think about the life-affirming and empowering potential of recovery, and about how we allocate our scarce resources, the more I believe that the recovery-based—as opposed to disability-based—practice of psychiatry has much more to offer the future of our patients, our profession, and our nation, than the current status quo.  For the sake of Frank’s recovery, and the recovery of countless other men and women like him, maybe it’s time to make that happen.


Is the Criticism of DSM-5 Misguided?

December 15, 2011

In 2013, the American Psychiatric Association will publish the DSM-5, the next edition of its diagnostic manual.  Public reaction has, thus far, not been favorable.  Critics decry the lowering of diagnostic thresholds in existing criteria; the conception of new diagnoses seemingly “out of thin air”; the radical overhaul of entire sections (like the personality disorders); and the secrecy under which many of the earlier planning stages were held.

Much of the criticism, including that from its most vocal critic, Allen Frances (lead author of the current edition, the DSM-IV), laments the expansion of diagnostic criteria.  They argue that this may increase the number of “mentally ill” individuals and/or pathologize “normal” behavior, and lead to the possibility that thousands—if not millions—of new patients will be exposed to medications which may cause more harm than good.

The American Psychological Association, the British Psychological Society, and the American Counseling Association have expressed their opposition publicly.  An online petition from the Society for Humanistic Psychology (part of the APA) has garnered nearly 9,000 signatures in fewer than 60 days.

I understand and sympathize with the critics, particularly against the DSM‘s emphasis on “user acceptability” over validity (and, in the interest of full disclosure, I did sign the petition).  But I wonder whether the greater outcry against the DSM-5 is somewhat misdirected. The DSM-5 may very well turn out to be a highly flawed document, but that’s all it will be: a document.  Whether it results in the “overdrugging and overdiagnosing” predicted by critics like Frances is not the primary responsibility of its authors, but of those who will use the book.  And this is where the outrage should be directed.

First of all, let’s just state the obvious:  it is impossible to write a comprehensive, scientifically valid catalog of all mental illnesses (particularly when some argue convincingly that mental illness is itself a false concept).  When we’re talking about conditions that have both biological and sociocultural origins (in fact, this has long been part of the distinction between “neurologic” and “psychiatric” disease), it seems clear that a diagnostic manual will never capture the full spectrum of psychiatric disorders.  Even if we included semi-accurate biological markers in the diagnostic criteria—a Holy Grail we’re far from attaining—mental illness will always, in the end, depend primarily upon the patient’s subjective experience.

Thus, the DSM-5, like all DSM’s before it, will be, almost by definition, incomplete or deficient.  It will be a descriptive tool, a taxonomy, a guidebook, featuring the authors’ best guess as to what might constitute a treatable condition.  For example, in real life there is no one thing called “major depressive disorder” as it appears in the DSM-IV (in fact, there are 1,497 variations).  Nonetheless, we use “MDD” to label all of our patients with these combinations of symptoms, because it’s the best fit.  But a good mental health professional doesn’t treat MDD, he or she treats the person with MDD.  Calling it “MDD” is only necessary for insurance billing, for drug companies to get FDA approval for new pharmaceuticals, and for patients and docs to give a name to (and, if necessary, demystify) their condition.

In other words, the danger lies not in the label, but in how we use it.  In fact, one might even argue that a lousy label—or a label that is so nonspecific that it applies to a broad swath of the population, including some in the “normal” part of the spectrum (wherever that may be)—may actually be beneficial, because it will be so meaningless that it will require the clinician to think more deeply about what that label is trying to convey.

As an example, consider “chronic pain,” a label frequently applied to patients and written in their charts.  (Even though it’s often written as a diagnosis, it is really a symptom.)  “Chronic pain” simply implies that the patient experiences pain.  Nothing more.  It says nothing about the origin of the pain, what exacerbates or soothes it, how long the patient has experienced it, or whether it responds to NSAIDs, opioids, acupuncture, yoga, or rest.  When a new patient complains of “chronic pain” to a good pain specialist, the doctor doesn’t just write a script; he or she performs an examination, obtains a detailed history and collateral information, and treats in a manner that relieves discomfort yet minimizes side effects (and cost) to the patient.

Perhaps this is what we can do in psychiatry, even with the reviled new DSM-5 diagnoses like “Attenuated Psychosis Syndrome” or “Disruptive Mood Dysregulation Disorder.”  Each of these new “diagnoses” suggests something about the patient and his or her behavior or experience.  But neither one should predict a course of treatment.  In fact, a vague diagnosis should actually prompt the doctor to probe more deeply into a patient’s symptoms and determine their impact on the patient’s well-being and functional status (which may actually help improve disability evaluations, too).  On a population basis, the heterogeneity of patients given a diagnosis might stimulate further research (neurobiological, psychological, epidemiologic, maybe even anthropological) to determine more specific subtypes of illness.

Will the new diagnoses be “overused”?  Probably.  Will they lead to “overdrugging” of patients—the outcome that everyone fears?  I guess that’s possible.  But if so, the spotlight should be turned on those who do the overdrugging, not on the document that simply describes the symptoms.  This may turn out to be difficult: official treatment guidelines might come out with recommendations to medicate, insurance companies may require diagnoses (or medications) in order to cover psychiatric services, and drug companies might aggressively market their products for these new indications.  And there will always be doctors who cut corners, arrive at diagnoses too quickly and are eager to use dangerous medications.  But these targets, ultimately, are where the anti-DSM-5 efforts should be placed, not on its wholesale rejection.

In the end, one could argue that the DSM-5 is unnecessary, premature, and flawed.  Unfortunately, it simply reflects our understanding of mental illness at this point in time.  But is it a “dangerous public health experiment,” as Allen Frances has warned?  Only if we allow it to override our eyes and ears, our hearts and minds, and what our patients truly need and want from us.   In the end, it’s just a book.  What really matters is how we use it.


I Want a DSM Wiki

June 8, 2011

As most readers of this blog are well aware, the American Psychiatric Association will publish its latest version of the Diagnostic and Statistical Manual (the hallowed “DSM”) in 2013.  The next version will be version 5.  (Note, it’s “5,” not “V.”  This is so that follow-up versions can be named 5.0.1, 5.1, 5.1.1, etc.  Just like computer software.  I kid you not.)

The provisional criteria have been made public, and the APA invites anyone to comment on its website, dsm5.org.  (The full development process was not this transparent.  Allen Frances and Robert Spitzer, two dissidents, famously decried the “nondisclosure agreements” the book’s authors had to sign.  Spitzer even commented, “The intent seemed to be not to let anyone know what the hell was going on.”)

But as we get closer to the publication date, readers can have a closer look under the hood.  Anyone can surf over to their website and make comments.  Yes, now is your chance to let the leaders of the psychiatric profession know precisely what you think about the new “Somatic Symptom Disorder” diagnosis; challenge the possible removal of the “narcissistic” category; or just tell the authors that you think psychiatry is all a crock of s***.

In an interview published today on Medscape, David Kupfer, chair of APA’s DSM-5 task force, reports that this spirit of openness and flexibility will likely persist even after its publication.  He says the upcoming DSM-5 will be a “living document,” complete with an electronic version (probably online?) which will be “much easier to update and may even include links to videos and vignettes.”

That could be a big step forward.  Imagine: if you’ve never seen catatonia before, you might be able to click on the DSM-5 entry and see a video of a catatonic person.  If your patient doesn’t understand why you just diagnosed her with borderline personality, you can read her a descriptive vignette (so much more interesting than a checklist!) and she’ll get it.

My thinking is, why stop there?  Psychiatrists are already way behind the times when it comes to modern technology.  Our peers in other specialties get to use fancy doodads like MRI scanners and bypass machines and stents all day long.  We just sit around and talk to people.

And then it hit me:  the APA should create a DSM-5 wiki.

For those of you who have no idea what a “wiki” is, it’s a website developed collaboratively by users and visitors.  Any user can add content, and it’s edited in real time by other users.  Disputes are resolved by online discussion, and historical changes can be viewed by anyone.  Perhaps the most famous example of a wiki is Wikipedia, the online encyclopedia.  Those articles were not first published in a book somewhere; instead, they have been written by experts and non-experts alike, and are constantly being edited.  Wikipedia has, for better or for worse, come to replace conventional encyclopedias and is a remarkably accurate (and free) source of material.

Maybe the APA can do the same!  Let’s put the DSM-5 online and let people do whatever they want with it.

Imagine the uses.  A DSM-5 wiki would let clinicians chime in about what they think ought to be changed or added, like an interesting “subtype” of an existing disorder.  Similarly, scientists could share findings that might be relevant to diagnosis (like newly discovered biomarkers) and clinicians could share novel uses of off-label medications, therapeutic successes, and interesting case reports.

Each medication could have its own Wiki page, with complete FDA approval information and dosing.  Herbals could be included.  To be fair, pharmaceutical companies would have free access to their documents, but any changes made by industry would be flagged as such.  Users could even upload cost data to help patients find affordable generic alternatives.

But the APA needs to make an even stronger statement that we’re not just old guys sitting around smoking pipes.  We need to go balls to the wall.  We could allow users to upload videos of unique patient presentations (with the proper HIPAA safeguards in place, like black rectangles over patients’ eyes, etc), public-domain lectures by famous psychiatrists, and links to journal articles describing new and relevant findings.  We could also add references to fascinating psychiatry blogs like this one. (lol)

Patients could also upload their own experiences, in YouTube format.  Their videos would be cross-referenced to the relevant diagnoses and/or medications.  Videos with the most “hits” could win a prize.  Maybe we can link terms to their Urban Dictionary entries.

We could add clips from Hollywood movies depicting particular disease presentations.  We could add links to Amazon.com to purchase relevant books (and use the Amazon Associates revenue to help manage server costs).  We could include a Skype plug-in that would allow users to chat with other people logged on at the  same time.  We could even sell space to advertisers like Groupon (“10 sessions of psychotherapy for the price of 5 in Chicago!!”) or, for those over 21, porn sites (targeted specifically to readers of the “Paraphilias” entry).

Social media is the future, and the APA really needs to get with the program!  An animated GIF logo.  An MP3 theme playing in the background of each page.  A Flash-based interface (sorry, iPad users).  The APA could even create new, edgy slogans for itself and for the DSM.  For instance, it’s not DSM-5 anymore, it could be “D5M-ph!\/3″.  It’s not just a “living document,” it can be the most 4w3soM3 social media psychiatry destination on the planet!   OMG!!!!!!1!

Let’s do it.


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