American Psychiatric Association's diagnostic manual faces mounting criticism
The American Psychiatric Association is about to release the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM ). Criticism has been mounting for years about the classification system’s reliability and credibility. Some British Columbian academics and health professionals share a concern of many others: because of its ties to the pharmaceutical industry, the DSM-V, which comes out later this month, can’t be trusted.
“The direction [of the DSM-V] is in expanding the brackets of existing psychiatric disorders and creating new ones,” says UBC law professor Joel Bakan, who explored, among other things, the pharmaceutical industry’s influence over medical practice in his book Childhood Under Siege: How Big Business Targets Children. “I’m quite concerned because of the degree of connection between people putting it together and big-pharma companies.”
For proof, Bakan points to a staggering statistic: according to a study published in the peer-reviewed journal PLOS Medicine last year, 69 percent of the DSM-5 task force members reported having ties to the pharmaceutical industry.
“That’s alarming,” Bakan says in a phone interview. “I’m not a medical expert, but the big issue is the increasing involvement of the pharmaceutical industry not only in putting together diagnostic protocols like the DSM-V but in every other aspect of medicine. It has more and more control and involvement in research—there’s been a loss of independent research—and more and more control and involvement in journals and publications.”
More than 140 panel members plus another 29 task-force members were responsible for the revisions to diagnostic categories and the inclusion of new disorders in the latest DSM, which will be released during the APA’s annual meeting from May 18 to 22. The PLOS study also found that the most conflicted panels are those for which pharmacological treatment is the first-line intervention. Sixty-seven percent of those on the panel for mood disorders have ties to the pharmaceutical companies that manufacture medications used to treat these disorders or to companies that service the pharmaceutical industry. So do 83 percent of members of the panel for psychotic disorders, and 100 percent of those concerned with “sleep/wake” disorders—which now includes the highly controversial “restless leg syndrome”.
Specifically, doctors may have been paid to participate in drug companies’ speakers bureaus, may have received research grants from such corporations, or may have stock holdings in pharmaceutical companies.
Aside from such obvious conflicts of interest, another problem with the DSM-V is what American psychiatrist Allen J. Frances—chair of the DSM-IV task force who resigned from the DSM-V in dismay—refers to as the “medicalization of ordinary life”. (Frances has written extensively about the DSM-V’s ills. On May 3, he tweeted “#DSM5 run incompetently start to finish. Waste of time, money, and credibility. An aberration—don’t use it to judge all psych.”)
The pathologizing of normalcy is what prompted Kelowna psychotherapist Jason McCarty to join the International DSM-5 Response Committee. The coalition of health professionals and educators aims to raise awareness of the problems with the DSM-5, alert people about dangers of the new manual, and find practical alternatives.
“With the DSM-V, there’s the lowering of diagnostic criteria,” McCarty says in a phone interview. “So, say, where in the past you’d need to meet six different criteria [to be diagnosed with a particular mental disorder], now you may only need to meet four. So, possibly more people are being diagnosed, and that leads to further use of medication as well, often especially in children and the elderly.
“One area where the thresholds are being lowered is grief,” he adds. “Say a parent dies. If you have symptoms [of grieving] lasting longer than two weeks, then you can get a depressive diagnosis. But those symptoms are normal and natural.”
McCarty emphasizes that the committee is not antipsychiatry or antimedication. However, its members want overdiagnosing of mental disorders and the resultant overreliance on psychiatric medications to stop.
“A lot of practitioners prescribing [psychotropic] medications are GPs, not psychiatrists, and a lot of them have not had much training in actual psychiatric diagnoses,” McCarty says. “When a diagnosis is created, it takes a life of its own and everyone gets swept up by it. It’s the simple answer and, ‘Here’s some medication.’ ”
According to the June 2012 issue of the American Psychological Association’s Monitor on Psychology journal, almost four out of five prescriptions for psychotropic drugs in the United States are written by doctors who aren’t psychiatrists, and fewer of their patients receive psychotherapy than in the past. In 1996, one-third of patients taking antidepressants also received therapy; that figured dropped to one-fifth of patients by 2005.
The International DSM-V Response Committee has a started a petition that outlines its concerns and asks that they be resolved through “concerted, interprofessional, international dialogue and scientific research”. “Until then,” the petition states, “because there are safe and legal alternatives, clinicians, researchers, journal editors, healthcare planners, managers & commissioners, the pharmaceutical industry, and the media should avoid use of DSM-5 wherever possible.”
The 2012 PLOS study included recommendations based on the concerns that industry relationships can create a “pro-industry habit of thought”. These include requiring all DSM task-force members to be free of financial conflicts of interest and prohibiting individuals who have participated in drug companies’ speakers bureaus from DSM panel membership.
Although measures have been taken to help establish transparency in pharmaceutical research, still more needs to be done, according to Bakan. “In the U.S., they’ve instituted the mandatory registration of clinical trials, and that’s a good thing,” he says. “That was done in response to pharmaceutical companies burying negative data. But it’s a very weak response to a very pressing problem.
“The pharmaceuticals’ involvement in the DSM-V and other diagnostic protocols could be regulated but it’s not being regulated.”
John Livesley, a UBC professor emeritus of psychiatry, also resigned (in April 2012) from the DSM-V. Livesley was on the manual’s personality-disorder work group. In an email posted on the Psychology Today website, cosigned by University of Amsterdam professor Roel Verheul, Livesley called the DSM-V “seriously flawed”.