This week marks the long-awaited publication by the American Psychiatric Association (APA) of the highly controversial latest version of the “Diagnostic and Statistical Manual of Mental Disorders,” or DSM-5.
Some psychiatrists seem to be falling over themselves to reassure the public that they treat the manual only as a guide rather than a “bible” of diagnostic symptoms for mental illnesses.
But those protests seem disingenuous, given the enormous power the DSM exerts over who becomes diagnosed with a mental illness in the United States and how they are treated for it.
Psychiatrists are not the only health professionals who rely on the manual. It’s also heavily used by general practitioners, and they’re the ones who do most of the prescribing of psychiatric drugs in the United States.
Loose DSM definitions
In a scathing editorial published Monday in the Annals of Internal Medicine, Dr. Allen Frances — the psychiatrist who spent the last few years in charge of the effort to revise the DSM — advises physicians “to use the DSM-5 cautiously, if at all.”
He warns (as he has repeatedly before) that the manual has created “several high-prevalence diagnoses at the fuzzy boundary with normality,” which can lead to unnecessary and even dangerous treatments.
“Drug companies take marketing advantage of the loose DSM definition by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,” Frances writes.
“With the DSM-5,” he adds, “patients worried about having a medical illness will often be diagnosed with somatic symptom disorder, normal grief will be misidentified as major depressive disorder, the forgetfulness of old age will be confused with mild neurocognitive disorder, temper tantrums will be labeled disruptive mood dysregulation disorder, overeating will become binge eating disorder, and the already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further.”
A squandering of limited resources
But the DSM-5’s “diagnostic inflation” is harmful for another reason, as Frances explains:
[It] results in misallocation of resources, with excessive diagnosis and treatment for essentially healthy persons (who may be harmed by it) and relative neglect of those with clear psychiatric illness (whose access to care has been sharply reduced by slashed state mental health budgets).
Only one third of persons with severe depression receive mental health care, and a large percentage of our swollen prison population consists of true psychiatric patients with no other place to go. Meta-analysis shows that the results of psychiatric treatment equal or surpass those of most medical specialties, but the treatments must be delivered to patients who really need them instead of being squandered on those likely to do well on their own.
Conflicts of interest
Frances minces no words when it comes to criticizing how the DSM-5 was revised.
“I found the DSM-5 process secretive, closed, and disorganized,” he writes. “Deadlines were consistently missed. Field trials produced reliability results that did not meet historical standards. I believe that the American Psychiatric Association (APA)’s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product. The APA refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations.”
“Publishing profits trumped public interest,” he concludes.
‘Be an informed consumer’
Frances’ Annals of Internal Medicine editorial is aimed at physicians. In another essay, published this week on the British news-and-opinion website The Conversation, Frances had this to say to consumers:
My advice is to be an informed consumer. Never accept a diagnosis or a medication after a cursory evaluation. A psychiatric diagnosis can be a turning point in your life — as important as choosing a spouse or a house. Done well, it can lead to life-improving treatment; done poorly, it can lead to an inaccurate label and a harmful treatment.
People who have mild and transient symptoms don’t need a diagnosis or treatment. The likelihood is they are visiting the doctor on one of their worst days and will get better on their own. Medication is essential for severe psychiatric problems but does more harm than good for the worries and disappointments of everyday life. Better to trust time, resilience, support and stress reduction.