Does ‘Psychiatry’s Bible’ Need to Be Rewritten?
22 May 2013
Frank Farley, Ph.D from Institute of Psychiatry, University of London, England, is former President of the American Psychological Association and the Society for Humanistic Psychology
William W. Eaton, PhD, serves as Sylvia and Harold Halpert Professor and Chair of the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health.
Allen Frances was the chairperson of the DSM-IV Task Force, a former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine, and is the author of two new books: Saving Normal and Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5. Author of “Saving Normal”
Farley: the negatives now outweight the positives. It’s beyond fixing. There won’t be a DSM-VI.
It’s time to re-think the whole concept of diagnosis … break out of the biomedical model and include bio-psycho-social cultural model. DSM has run out of juice. We need fresh thinking on diagnosis.
Frances: DSM is good, actually wonderful is used well. It could be horribly harmful if …
Once the words are written, they take on a life of their own, and the drug companies have such tremendous marketing power that they’ve shanghaied the DSM and they’ve succeeded in convincing people that the problems of everyday life are really mental disorders due to a chemical imbalance, treatable by a pill.
So we have a remarkable degree of diagnostic inflation.
1/4 of the population now qualifies for mental disorder
1/5 people now take a psychiatric medicine.
This is out of hand. It has to be controlled. DSM-5 will make all this much worse by turning diagnostic inflation into hyper-inflation.
However, DSM-5 is enormously useful at diagnosing people who have clear-cut, severe psychiatric disorders.
There is no substitute for DSM-IV or DSM-5. I wish there was.
05:35 … Frances’ promise of a psycho-social model would be very useful if it could be delivered.
we have 1 million psychiatric patients in prisons because they’re not receiving adequate care in the community and a decent place to live
If they were diagnosed accurately and treated effectively, it would be a better world.
So the attack shouldn’t be if DSM is good or bad, it shoudl be how do we get a mental health system because right now we don’t have one.
Farley: Right now, we need to put DSM on a diet, right? It’s gotta be slimmed down, and targeted, and more precise
Frances: and we have to stop the drug companies from having the right to market
Eaton: We are the only country in the world that permits DTC advertising of medical products
DTC advertising: selective serotonin reuptake inhibitors
07:29 Prisons are now the mental hospitals of the 19th century. They have replaced …
50% of the people in prisons have severe or important mental illnesses
Bad Pharma: How drug companies mislead doctors and harm patients
by Ben Goldacre
Frances: psychiatry does as well as other medical specialties if it’s limited to its proper competence but if you take people with milder problems that more often than not really aren’t psychiatric disorders the placebo response rate is over 50% and medication is for the most part not helpful and very often quite harmful, and always expensive.
Farley: Asperger syndrome: the services will be restricted and it will be harder to get services
-> educational and familial implications of this change.
Frances: DSM was never created to determine school services DSM is a clinical manual, with clinical purposes.
We need to de-couple the educational decisions from a manual that really wasn’t developed to help make them
Eaton: biology and genetics, BUT the causes of mental disorder that we know are actually social
Farley: that fits into the bio-psycho-social-cultural model, which is an elusive model for sure, but one that I think we need to pursue because the reductionist model by NIMH just failed and they’re pushing hard for lab-based tests … nature and nurture are both involved.
Frances: the NIMH made a terrible error in overselling its overselling its hability to contribute to a diagnostic system.
The decade of the brain in the 1990’s revealed a tremendous amount of fascinating neuroscience but yielded nothing that was useful for clinical science.
The brain is the most complicated thing in the universe and its secrets are revealed only very, very slowly.
It will be a long time before we understand the causes fo mental illness on a biological basis.
We meanwhile need to be treating patients.
psycho-social models are absolutely crucial to understand mental illness but we don’t have at this point a psycho-social model of diagnosis
“Paradigm shif for the future”: fine, current psychiatric patients have desperate needs which are not being met
ALL THE CRITICISM YOU HEAR IS SCARY
80% of the medication prescribed is done by non-psychiatrists (primary care doctors) after brief visits (7 minutes)
We now have more overdoses from prescription drugs that from street drugs
YOU SHOULD KNOW MORE ABOUT DIAGNOSES THAN YOU DO ABOUT THE HOUSE YOU BOUGHT
You should never accept the diagnoses after 7 minutes with the doctor.
Most people that go to a primary care doctor and get a medication will get better on their own. The placebo response rate is enormous. People are resilient. Life changes, people get better.
Frecuent OVERUSE OF MEDICATIONS but … you’re probably being UNDERTREATED.
EATON: The worst problem is not DSM. It’s DTC advertising.
FARLEY: psychotherapy works. Talk therapy works by and large. The particular method of psychotherapy doesn’t really matter all that much. Wheather it’s psychoanalysis or dynamic approach, or cognitive behavioral approach, etc.
Recognition of Psychotherapy Effectiveness
American Psychological Association.
Psychotherapy. 2013, Vol. 50, No. 1, 102–109
EATON: Global Health Unit: Interpersonal therapies, psychotherapies, cognitive behavioral therapies, trauma-focused behavioral therapies …
you can teach people with a high school education in a relatively short time to give a therapy which is effective
Frances: THERE IS NO BUDGET TO PUSH PSYCHOTHERAPY
Insurance companies: they take a very short-term view of what is more expensive this year, worried that they won’t have that client for the longer haul
Psychotherapy is just as effective, perhaps more effective, with fewer side effects for mild-to-moderate problems. It doesn’t work well alone for severe problems.
psychotherapy lasts, whereas drugs have to be taken often for a lifetime
Psychiatry now = pill-dispensing
Eaton: “NIMH would say: we need to make VALID diagnoses”
The use of the term VALID for diagnoses is not quite appropriate.
Validity is for measures, not for diagnoses.
We don’t have that kind of VALIDITY in psychiatry, and it’s possible we will never have.
The concept of validity concerns the degree to which a measurement or study reaches a correct conclusion. A measurement or study may lead to an incorrect (invalid) conclusion because of the effects of bias. The variability seen with bias is systematic or nonrandom and distorts the estimated effect. In Figure 10–1, the amount of bias can be determined by the degree to which the shots are off target in D. Unfortunately, in medical research the truth (bull’s-eye) may not be known, or there may be no “gold standard” for comparison. Consequently, the degree of bias often is difficult to determine. There are two different types of validity, internal validity and external validity.
Medical Epidemiology, 4e © 2005 (Raymond S. Greenberg, et al) > Chapter 10. Variability & Bias
DSM categories and dimensions in clinical and research contexts
Int. J. Methods Psychiatr. Res. 16(S1): S8–S15 (2007)
HELENA CHMURA KRAEMER
Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
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