Psy­chi­atric evo­lu­tion

DSM-5 changes draw mixed re­ac­tions

Modern Healthcare - - THE WEEK IN HEALTHCARE - Andis Robeznieks

For­mer Pres­i­dent Bill Clin­ton may be the head­liner at the May 18-22 Amer­i­can Psy­chi­atric As­so­ci­a­tion con­ven­tion in San Fran­cisco, but the re­lease of the fifth edi­tion of the Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders, known as DSM-5, will steal the show.

The man­ual of­fers a mix of sweep­ing and sub­tle changes that will have a ma­jor im­pact on the prac­tice of psy­chi­a­try and the treat­ment of men­tal and be­hav­ioral prob­lems for years to come. Though the writ­ing process has been dogged by con­tro­versy be­cause of the fi­nan­cial ties that many of its au­thors have with the phar­ma­ceu­ti­cal in­dus­try and by crit­i­cism that it seeks to turn rou­tine life events into med­i­cally treat­able episodes, this lat­est edi­tion has mostly been greeted as hav­ing enor­mous ben­e­fit for the pro­fes­sion and for peo­ple with men­tal dis­or­ders.

One of its ma­jor shifts in­volves mov­ing psy­chi­a­try fur­ther in the di­rec­tion of the hard sciences as dis­or­ders be­come in­creas­ingly viewed as mal­func­tions in the bio­chem­i­cal pro­cesses of the brain. Dr. Jerry Halver­son, pres­i­dent of the Wis­con­sin Psy­chi­atric As­so­ci­a­tion and med­i­cal di­rec­tor for adult ser­vices at Rogers Me­mo­rial Hos­pi­tal in Oconomowoc, Wis., said the re­vi­sions take into ac­count “an ex­plo­sion of un­der­stand­ing” into the bi­ol­ogy of some dis­or­ders.

This should of­fer more ob­jec­tive cri­te­ria so that pa­tients don’t re­ceive “three dif­fer­ent di­ag­noses from three dif­fer­ent doc­tors and get three dif­fer­ent cour­ses of treat­ment,” he said. The evo­lu­tion in un­der­stand­ing some of the bi­o­log­i­cal un­der­pin­nings of men­tal dis­or­ders may also help pri­mary-care physi­cians by pro­vid­ing tools for as­sess­ing the men­tal health needs of their pa­tients.

The ma­jor changes in DSM-5 span most of the con­tro­ver­sial top­ics in con­tem­po­rary psy­chi­a­try. They in­clude chang­ing the di­ag­no­sis and treat­ment of de­pres­sion dur­ing pe­ri­ods of be­reave­ment or grief; com­bin­ing old cat­e­gories of sub­stance abuse into one cat­e­gory and link­ing patho­log­i­cal gam­bling with sub­stance- abuse dis­or­ders; adding “binge eat­ing dis­or­der” to the cat­e­gories of feed­ing dis­or­ders; look­ing more closely at the be­hav­ioral symp­toms of post-trau­matic stress dis­or­der; and re­mov­ing Asperger’s syn­drome as a sep­a­rate di­ag­no­sis (de­fined by May­ as a “de­vel­op­men­tal dis­or­der that af­fects a per­son’s abil­ity to so­cial­ize and com­mu­ni­cate ef­fec­tively with oth­ers”) and in­clud­ing its symp­toms as part of the broader autism spec­trum dis­or­der.

While crit­i­cism of changes to the DSM are ex­pected—psy­chi­a­try is a highly con­tentious field whose prac­tices have taken dra­matic twists and turns over the decades—this edi­tion has drawn fire from an un­likely source. Dr. Allen Frances, chair­man of the task force of DSM-IV, the pre­vi­ous edi­tion of the man­ual, said DSM-5 will do noth­ing to solve cur­rent prob­lems in­volv­ing too many peo­ple not get­ting the treat­ment they need while oth­ers are be­ing pre­scribed drugs they shouldn’t take.

“The big­gest mis­rep­re­sen­ta­tion is that it’s an of­fi­cial sys­tem, but no one needs to use it,” said Frances, a for­mer chair­man of the Duke Univer­sity School of Medicine’s psy­chi­a­try depart­ment and cur­rently pro­fes­sor emer­i­tus. “I’m ad­vis­ing peo­ple not to buy it, not to teach it and not to use it.”

Fran­cis is the author of the book Sav­ing Nor­mal: An In­sider’s Re­volt Against Out-of-Con­trol Psy­chi­atric Di­ag­no­sis, DSM-5, Big Pharma, and the Med­i­cal­iza­tion of Or­di­nary Life. “We can’t just ig­nore DSM-5 and be happy,” he said. “We have to look at the ex­ist­ing pic­ture and prob­lems of quick-draw di­ag­no­sis and over-med­i­ca­tion.”

Those on the front lines of pay­ing for psy­chi­atric dis­or­ders so far ap­pear san­guine about the changes, which they feel won’t have a ma­jor im­pact on the num­bers of peo­ple seek­ing treat­ment, even if it does af­fect the na­ture of the treat­ments be­ing of­fered. Dr. Mark Fried­lan­der, chief med­i­cal of­fi­cer for be­hav­ioral health at the in­surer Aetna, said his com­pany and the rest of the payer com­mu­nity sup­port ev­i­dence-based cri­te­ria and feel DSM-5 will make no dif­fer­ence to their op­er­a­tions.

“Ser­vices are gen­er­ally con­sumed based on clin­i­cal need, so whether a per­son can have a di­ag­no­sis that falls into this cat­e­gory or that is not as im­por­tant as eval­u­at­ing any func­tional im­pair­ment a per­son may have,” Fried­lan­der said. “We’re look­ing at symp­tom sever­ity, not spe­cific di­ag­nos­tic cat­e­gories.”

The DSM-5 panel came un­der fire last year in PLoS Medicine, an on­line jour­nal, when re­searchers from Har­vard and Tufts uni­ver­si­ties crit­i­cized the “per­ni­cious prob­lem” of the DSM-5 task force mem­bers’ fi­nan­cial as­so­ci­a­tions with the phar­ma­ceu­ti­cal in­dus­try. The au­thors wrote that the panel’s dis­clo­sure pol­icy had not been ac­com­pa­nied by a re­duc­tion in fi­nan­cial con­flicts of in­ter­est. “Trans­parency alone can­not mit­i­gate the po­ten­tial for bias and is an in­suf­fi­cient so­lu­tion for pro­tect­ing the in­tegrity of the re­vi­sion process,” they wrote.

Dr. David Kupfer, chair­man of the DSM-5 task force, said in an e-mail that the panel’s stan­dards were more strin­gent than sim­i­lar panels at the National In­sti­tutes of Health or the Food & Drug Ad­min­is­tra­tion. “In 2012, 72% of the 153 mem­bers of the DSM-5 Task Force and Work Groups re­ported no re­la­tion­ships with the phar­ma­ceu­ti­cal in­dus­try dur­ing the pre­vi­ous year,” Kupfer said.

Even the crit­ics down­played the drug in­dus­try’s role in set­ting the new di­ag­nos­tic cri­te­ria. The new man­ual may be “ex­ploited by pharma,” said Duke’s Fran­cis, but any po­ten­tial ar­eas of ex­ploita­tion were not “in­sti­gated” by drug com­pa­nies. “I think the phar­ma­ceu­ti­cal in­dus­try had no in­flu­ence on this. Th­ese are very bad de­ci­sions made with clean in­ten­tions.”

Psy­chi­a­trists, like other physi­cians, don’t nec­es­sar­ily fol­low their pro­fes­sional so­ci­eties’ guide­lines. But the DSM-5 is more likely than most to dif­fuse quickly through to clin­i­cal prac­tice. “It’s ob­vi­ously go­ing to be a big change,” said Halver­son, who took part in field test­ing some of the man­ual’s symp­tom scales.

One of the ma­jor out­stand­ing con­tro­ver­sies in­volves the changes in di­ag­noses of de­pres­sion and grief. Halver­son said the in­tent was not to “pathol­o­gize be­ing sad af­ter a loss,” but to rec­og­nize that grief can trig­ger de­pres­sive symp­toms—in­clud­ing what the APA de­scribes as cor­ro­sive feel­ings of worth­less­ness and self-loathing—es­pe­cially in pa­tients who ex­pe­ri­enced th­ese symp­toms be­fore. The in­tent, he said, is to get peo­ple the treat­ment they need when needed, “in­stead of suf­fer­ing for a cou­ple of months.”

Frances dis­agreed. He noted that DSM-IV called for treat­ing peo­ple who were sui­ci­dal or delu­sional and couldn’t func­tion. But it oth­er­wise called for “watch­ful wait­ing.” Most peo­ple can get bet­ter with­out med­i­ca­tion or a di­ag­no­sis, he said.

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