These are quotations from a BBC special on the next edition (it will come out in 2012) of the psychiatric DSM.
The catch-all mental disorder category NOT OTHERWISE SPECIFIED — which will apparently be abundantly featured in the forthcoming edition — allows UD (and you too) to anticipate lifelong toxic drug treatment for something or other.
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“The relationship between the pharmaceutical industry and the American Psychiatric Association” is at the heart of Diagnostic and Statistical Manual.
“Each edition doubles the number of diagnoses.”
“A seemingly small change in adding diagnostic criteria can create a whole other population to prescribe a medication for… Most of the categories have a not-otherwise-specified diagnosis…. A person is exhibiting some mood symptoms but those symptoms are not that severe. When you have that kind of (NOS) prescription, you are inadvertently pathologizing what could be a normal part of [life].”
“If you create a criteria, and people appear to meet the criteria… well, many kids appear to have the criteria for bipolar pediatric disorder… This leads to treatment with a group of medicines that are among the most toxic in medicine…. Children of one, two, three, are put on these drugs…”
“There are barely short-term studies, let along long-term studies, on childhood bipolar disorder.”
“The majority of DSM panel members have financial ties to the industry. In the panels on mood disorders and schizophrenia, one hundred percent do… These are THE categories for which drugs are the standard treatment.”
“Psychiatry is undergoing a crisis of credibility… Senator Grassley has asked the APA leadership for their financial records…”
“The APA must develop more rigorous COI policies… Unrestricted research grants, for instance, are currently excluded in their COI policy…”
“The DSM decisions are worth $25 billion to the drug industry.”
“This whole business of sub-clinical disorders… will interest the drug industry enormously…”
“This could cause the rates of mental disorder to sky-rocket. … The pharmaceutical industry will be thrilled with broader, more open descriptions of disorders…”
Now UD, let’s calm you down.
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UD thanks Daniel Carlat.
August 6th, 2009 at 12:04PM
When I see Nurse Ratchet (or Ratchett? Oh hell, Lois Chiles), I think "disintermediation." It’s a psychological thing I have (I know, you don’t want to see it).
Frontal lobotomies became a popular treatment for certain psychiatric diseases, because, I suppose, they often worked. Working on the theory that, if some lobotomies are good, more are better, a neurologist got the idea that this surgery could be done percutaneously (and blindly) by simply inserting a surgical knife in the supraoptically (superciliously) and swishing the knife back and forth. The neurologist went on barnstorming tours demonstrating this technique and so, cut out the middle man.
August 6th, 2009 at 1:14PM
One thing that I think gets overlooked in focusing so much on psychiatry is that this issue of defining disease is fundamentally part of all medicine, especially now, as more and more of health and illness has become chronic and lifestyle related, rather than acute. The definition of when someone has high cholesterol or high blood pressure has changed over time. In fact, there is a long-term interaction between evolving treatments, insurance coverage, and the definition of illness that is as evident in the changes in the ICD as in the DSM. You’ll find plenty of NOS in the ICD manual, too.
August 7th, 2009 at 6:51AM
True, but we can measure things like blood pressure. So even if we tussle about where one’s going to set “high,” we at least have some empirical basis for discussion and treatment.
August 7th, 2009 at 10:36AM
But, we do also have clinically relevant measures for most mental illnesses. And, have you ever tried to measure low back pain? There are areas of physical health that are hard and easy to measure and areas of mental health that are hard and easy to measure.
The state of the technology today means that most mental illnesses rely on patient reports of behavior, but they are reasonably accurate for most major disorders. As our scientific understanding of brain activity is enhanced through better scanning and other data, diagnostic accuracy will be improved. Seems to me you are erring by measuring those trying to diagnose and treat mental disorders by an unreasonable standard. Practitioners can only use the technologies that are available to them, to the best of their abilities (and I’ll certainly concede that too many fall short in that latter area).
My broader point is that the sins you see in psychiatry are found in all areas of medicine. For an example in another area, you may have seen the recent article on the use of spinal cement for osteoporosis, a procedure used by physicians over 80,000 times per year at a cost of $1,500 to $2,000 to patients and Medicare. Since we don’t approve medical procedures with even the level of review that the FDA does for drugs, we finally got around to a reasonable study more than a decade after its introduction. The study found no effect above placebo. Estimates are that one-fifth to one-third of what physicians do has no clinical benefit (and then if you factor in that which has greater clinical benefit than its cost, you can identify much more). On the other side, studies of what care the best physicians give indicate 50 percent of recommended care with proven benefit is never given.
So, the problems of definition of disease, conflicts of interest, diagnosis and treatment, conflicts of interest, over-treatment and under-treatment, self-serving conflicts of interest, and the rest are simply not confined or even, I would argue, more common, in psychiatry.
August 7th, 2009 at 11:43AM
I take your point; there are diagnostic uncertainties in virtually all of medicine. And yes, I did see the spine story, which makes your point for you perfectly.
And of course I’m not inclined to disagree with you that COI and the rest thrives in all branches of medicine. I’m sure that’s true, and all I can say is that if it looks as though I’m concentrating too much on psychiatry, there are only so many hours in the day… But I’d also point out that psychiatry IS a more fertile field for misdiagnosis, misbehavior, and injury for a couple of reasons…
Maybe the basic reason is that psychiatry is about Being. There’s back pain and there’s pain in the ass and there’s tumors and all sorts of physical stuff — and it’s all distributed this way and that way in the population. But everybody gets a seat on the neurotic – to – psychotic train. There’s SO much money to be made in psychopharmaceuticals because everyone who exists is often unhappy and often mentally unsettled. Everybody’s got a mommy-daddy-trauma story.
Not to get too personal, but I’m about the only person I know (besides my husband) who hasn’t been to psychotherapy or been prescribed a mood pill of some sort at some time. Everyone’s susceptible to ubiquitous ads on tv and on the metro (I don’t watch tv; I see the ads on the metro) that show unhappy people and ask ARE YOU UNHAPPY? How likely is it that on any given day on some level the answer to that won’t be yes?
Because the mood-pill-taking population is one hundred percent of planet Earth (take note of what’s going on in China and India and other countries where the population hasn’t yet been able to pump itself full of lifelong anti-depressants – these are THE exciting new pharma frontier), the money involved here is of course enormous.
Consider the pharmaceutical market generally.
The pharmaceutical global market will be over 1 trillion dollars by 2012; right now
Use of anti-depressants and other mood drugs is growing, I believe (I’m happy to be corrected) much more quickly than use of most other drugs.
When there’s this much money involved, there’s a special level of corruption among professors, scientists, and doctors that just has to go with it. People are greedy. Not everyone’s greedy. Maybe even among greedy people most of them are ethical enough not to steal and compromise patients’ health and lie about experimental results, etc., etc. But there’s gotta be a lot of them that are going to be corrupted by so much money. And there’s gotta be a lot of organizations that’ll be corrupted by so much money. That’s my main point, in response to yours — pharma is special.
August 9th, 2009 at 9:24AM
I’m sure there will be areas where we agree to disagree, and I’ll try to avoid writing a thesis, but…
Spending on mood drugs, while certainly no shrinking violet, has not been the fastest growing drug class. For most of the 1990s, the lipids and other cardiovascular drugs dominated. More recently, it’s been the diabetes and other metabolic drugs.
Yes, spending on pharmaceuticals is large and growing. But, spending on hospitals is much larger. Spending on physician services is much larger. And, while pharmaceutical spending was among the fastest growing areas of spending 5 years ago, in the past few years, it has moderated dramatically, with growth rates behind almost every other area of health care spending. The money in pharma is no more special than many other areas of health care.
And while that spending on psychotherapeutic drug spending has grown, it’s reduced another area of mental health spending–inpatient psychiatric hospitalizations. Some of the people getting these drugs are people we used to warehouse in state mental facilities with Nurse Ratched. I’m not saying this change is all goodness and light, but there are a few babies in that bathwater.
Two quick confessions–no therapy or psychotherapeutic drugs in my medical history (so far). Only about 15 percent of the population uses any mental health services in a given year. So, your experience with your friends may say more about DC (grin) than it does about the rest of the country. Because of stigma and poor insurance coverage, it’s likely that the number of people with true mental illnesses who go untreated is greater than the unnecessarily treated. Here’s where we may disagree. To me, it’s not about "being". It’s about chemical, electrical, hormonal, etc. disruptions in the brain, just like heart disease, just like metabolic disorders, just like the rest. It’s just harder to define "normal" and harder to diagnose variations from that standard.
Second quick confession–GTWMA as a young, untenured prof with a wee one on the way and an interim dean’s 2 sentence P&T review in his pocket is asked to "consult" on a lit review article with a leading scholar and a pharma in-house writer. Both the $ and the CV line offer enough temptation to accept. A thoroughly putrid experience ensues, perhaps because of my comments on the initial in-house draft. AFAIK, article is never published. I made my choice then. Never again. I’m poorer in one way for it, and richer in many others.
Maybe that experience has helped me see how some people I know chose the other path. And that’s my point–the choice. Pharma’s difference isn’t the money or because it’s about "being". It’s a whole combination of things–the money, the for-profit aspects, the corporate influence, the fact that both illness and treatment are socially determined. The exact combination in different areas of health care differs, but they are differences in degree, not in kind.
And, the fact is that is how more of our future health care world will be. There will be medicines and treatments that will not simply repair the broken, but enhance the well. We’ll choose, individually and collectively, what the exact shape of that path will be.
August 9th, 2009 at 10:53AM
Don’t worry about writing a lot. You’re a really good writer – and you’re helping me understand things.
I did assume that mood drugs were, if not the biggest seller, a very big one — It was just reported, for instance, that anti-depressant use in the US doubled in the last ten years, and that seems to me an impressive and of course disturbing jump… I see no reason (given what we’ve both been describing in terms of uncertainty of diagnosis) why that won’t keep jumping.
In your last paragraph you talk about meds and treatments that will “repair the broken [and] enhance the well.” But my point about psych drugs is that many of them do a third thing — They take the well – or the reasonably well – and make them unwell, make them dependent, subject them to very strong, toxic drugs. The stories about 2-year-olds on antipsychotics and young boys doped to the gills with Ritalin are just the most dramatic instances of this; the way such victims often become lifelong druggies is also one of the more obvious scandals.
But — and this is not only restricted to DC, though I certainly see your point about the peculiarities of that affluent, neurotic, indulgent culture — there are also millions of normal adult Americans, I believe, taking expensive mood pills they don’t need … pills that do them damage of many sorts.
I certainly know that there are many clinical depressives in the world, and I’m thankful, when I see them stabilized, for the anti-depressants they’re on. But I also know that just as zillions of fools waste their time on psychotherapy for themselves year after year, so zillions waste their money on anti-depressants. (Often, of course, they’re the same fools).
This is not about, to use your words, enhancing the well — unless you believe that the money Michael Jackson spent on surgery and opioids enhanced him.
Mood pill pharm’s special for the reasons you cite and for one more: I think it’s part of a general pacification and demoralization of the population that’s bad for democracy. This essay makes the point well, especially toward the end:
http://www.margaretsoltan.com/?p=15533
August 9th, 2009 at 3:08PM
I can write more later, but did you know that from the mid 1990s to 2003, suicide rates among every age group between 10 and 24 dropped dramatically, and overall 25% reduction in the suicide rate?
The year the FDA announced the black box warning, teen AD use dropped dramatically….and the teen suicide rate rose 18%.
August 10th, 2009 at 8:32AM
Thanks for your compliments on my writing. I’ve pointed more than a few of my friends to UD. As I’m less than a month past my annual trip to the Delaware shore, I also hope you are enjoying your time.
I guess I don’t see the big gulf between antidepressants and, say, Vioxx, that you do. Used appropriately, both offer some significant benefits to a segment of the population. Used inappropriately, they can both harm the reasonably well. And I don’t see that end with pharmaceutical treatments. The same could be said for gastric bypass, spinal cement, surgery for low back pain, and a host of other ailments and treatments. The critical feature for me seems to be the uncertainty (or maybe ambiguity) in diagnosis and appropriate treatment. Mental health care may certainly have more of that, but I see that largely as a state of medical technology, not a critical permanent distinction between mental and physical health.
Where a new treatment of any type is developed, there will always be those with a financial interest to expand its use. That will occur by trying to make sure all who have the illness by the current definition get access to it. Because humans are imperfect, it will also happen by pushing the ethical envelope on who is ill, by expanding illnesses for which the treatment can be used (e.g., off-label use in drugs), and by changing the definition of the disease. Treating hypertension begats treating pre-hypertensives begats off-label use in children begats….
There are two areas where I disagree with McLaughlin. First, I see the growing use of pharmaceutical use for mental health as part of a broader and more complex trend within health care. Because we’ve banished much of the acute causes of death to the latter period of life, most health care is now about quality of life. No one NEEDS a knee replacement, in the sense that it is life-threatening. Instead, it’s about enhancing quality of life through reduced pain and improved mobility.
As health care has become more and more about managing quality of life within a lifetime defined by an aging body slowly developing more and more chronic illnesses that are linked to lifestyle, the trend is not simply one of reduced autonomy and greater paternalism. In many ways, we see people taking a much greater role in defining and trying to control their health and quality of life. More than ever, I think many people see themselves as partners with their physicians in trying to improve their health or even see themselves as the driver of that bus. So, this trend of defining everyone to be sick is paired with a trend of people rejecting the "doctor knows best" brand of paternalism and trying to take greater control over trying make ourselves well. This isn’t a simple story of surrendering our autonomy.
Additionally, McLaughlin is writing for a British audience, where there are some differences. In the US, for example, the definition of "vulnerable adult" has clearly been moving in the other direction. The Olmstead case, for example, insists that states treat vulnerable adults in the least restrictive setting possible, furthering the movement away from institutionalization and towards integration in community settings. The Cash and Counseling movement in long-term care takes public money that used to go to nursing homes and gives it to older people to make their own choices about what services they want and who provides them.
The social changes we see are complex, and maybe McLaughlin has it right and I’m wrong. But, like the tides, there is always an ebb and flow. AD use doubled, but that very same paper also reported that those zillions receiving psychotherapy fell by 50% during the same period. Those footing the bill for that rise in AD use will spend money to try to improve diagnosis, will revise the rules that define when money can be used to spend on it, will create tiered pharmacy formularies to prevent that rise from continuing. And those who profit by it will respond.
In the end, it comes down to making your choices. I should probably exercise more and eat better. And I’ll try. But, I’ll also take my statin and my Omega-3, even if that undermines our democracy. Maybe I’ll try a little yoga or massage therapy and see if I can overcome the family genetics I was handed. I definitely think I’ll have a glass of red wine with my dinner tonight.
My dad died from his heart disease less than 6 weeks before my little girl arrived, an unexpected 32 week preemie. My goal is to be there to hold her little one with her, with or without the therapeutic state.