In a couple of weeks I will be in San Francisco for the American Psychiatric Association’s annual meeting, at which the latest edition of the APA’s diagnostic “bible”, the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, will be released. From the look of the program, you’d think this is much like when previous versions were released — gathered delegates will get to hear lots of explanation of how the manual will work, how it was developed, and what evidence was used to validate diagnoses. There are very few papers that could be considered even remotely dissenting.
But appearances can be deceiving. Last week the National Institute of Mental Health — the peak US mental health research body — delivered a body blow to the authority of the DSM by announcing that it was abandoning the manual in favour of its own Research Domain Criteria (RDoC).
This is a new phase of the controversy that has dogged the DSM-5 at every turn. Petitions opposing the project have garnered the signatures of thousands of clinicians. The revision process has been attacked for being kept behind closed doors, and for favouring the pet research areas of expert committee members. The corporate media — usually uncritical of mainstream psychiatry — has reported substantial criticisms of proposed changes. The taint of academic psychiatry’s incestuous relationship with Big Pharma has fed accusations of financial influence. And the psychiatrists who headed DSM-III and DSM-IV — Robert Spitzer and Allen Frances — have attacked the DSM-5.
Even on the aims its creators set, the DSM-5 is a failure; an incoherent compromise and a mess. Significantly, its contents will reflect the impasse of the diagnostic paradigm that became hegemonic with the DSM-III in 1980, following a “revolution” in diagnosis designed to save US psychiatry from its profound crisis in the 1970s. It will be a further sign of the failure to create a “scientific” basis for psychiatry through symptom-based diagnoses, as NIMH director Thomas Insel has argued on his blog.
But the authors of DSM-5 also wanted the kind of quantum leap Insel advocates. When they started work over a decade ago they saw their task as going beyond simply describing disorders in terms of the symptoms and behaviours (the DSM is currently silent as to the “aetiology”, or cause, of almost all the disorders it defines). Instead they would align diagnoses to the “underlying” genetics and neurobiology. Yet as they proceeded it became increasingly obvious that there was insufficient evidence for this shift. More importantly, the biomedical model was increasingly being challenged from a number of directions: A series of major scandals involving kickbacks from drug companies to psychiatric “thought leaders”, mounting public concern about the over-diagnosis and gross overmedication of adults and children, and the growing evidence that many top-selling psychiatric medications (especially anti-depressants) worked little or perhaps no better than placebo.
It is no wonder that DSM-5 “innovations” like removing bereavement as an exclusion criterion for Major Depression are widely opposed. It feeds into a suspicion that psychiatrists and drug companies are cynically expanding potential markets for the expensive services and products they are selling.
The finished DSM-5 will have most of its original raison d’etre missing, some of the rewriting (e.g. personality disorders) relegated to an appendix, and a pall of controversy, mistrust and confusion surrounding it. The APA has suffered financially in recent years from a stagnant membership base and growing regulation of its financial ties with industry. Sales of the manual (not cheap at US$199) and its various guides to use form a major part of the APA’s annual revenue and seems to have been a driver for getting a new edition out for sale.
In the end politics hobbled the DSM-5 because the “objective” scientific advances its developers saw as being just around the corner proved to be a mirage.
The persistence of the neurobiological paradigm
While this is a setback for the DSM, it is far from being a defeat for the dominant neurobiological model of mental health and illness. As blogger 1 Boring Old Man points out, Insel is simply taking the established NIMH position to its logical conclusion by formally breaking with DSM-5. And the last half-century is proof of how profoundly that model shapes psychiatric research and practice. No matter how lean the pickings they deliver, biologically based approaches remain powerful and those who question them tend to be sidelined. You can see this in Insel’s alternative program for devising new diagnostic boundaries:
- A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
- Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
- Each level of analysis needs to be understood across a dimension of function,
- Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
Such assumptions are little more than speculative, yet they are presented as conclusive. They serve to close off avenues of research that fall outside their boundaries rather than open them up. They point to the imperviousness of the dominant biological paradigm to evidence that contradicts it. In the words of Samuel Beckett, “Try again. Fail again. Fail better.”
Another example of this is the set of arguments being put by Patrick McGorry and his collaborators here in Australia. When I last blogged about McGorry he was arguing for early intervention in young people deemed to be at ultra high risk (UHR) of psychosis. The intervening period has not been kind to this aggressive treatment approach, and last year he spoke against having UHR included as a diagnosis in the DSM-5. But this doesn’t mean he has abandoned the UHR concept, despite further setbacks to its validity and usefulness. For example, his team last month published a paper showing that anti-psychotic drugs are not more effective than supportive approaches and CBT in preventing “transition” to psychosis in a large group of UHR patients. More striking — and not noted in the abstract but buried in the text — is the fact that the patients who did the best were the ones who refused any kind of intervention!
Yet this has not stopped McGorry more recently defending such interventions in a sharply worded letter to the leading Australian psychiatry journal:
With respect to interventions, it is simply not true to say that there is ‘even less evidence’ of which treatments are effective for those at risk. Two meta-analyses (Preti and Cella, 2010; Van Der Gaag et al., 2013) both show, on the basis of 10 randomised control trials with the ultra-high risk for psychosis concept, that treatment is very effective in reducing risk with the number needed to treat (NNT) between four and nine. This indicates real potency of treatment in reducing risk and also underscores the fact that cognitive behavioural treatment (CBT) is the most appropriate first- line treatment. This should defuse the controversy surrounding this issue, which has been fuelled by ideological currents and confused with disinformation (McGorry, 2012).
The failure of the UHR concept to live up to its promise has also not stopped McGorry and his collaborators from spreading the gospel of his broader “clinical staging” model, which argues for the greatest intervention in early (or pre-illness) phases of various disorders. It seems that this is to be applied to every mental disorder, with depression, bipolar disorder, and even borderline personality disorder being redefined so as to find “at-risk” symptoms in young people. The logical extension of this model, originally developed for the treatment of cancer, has not been lost on its proponents, and they openly argue that people with established chronic mental illnesses should be treated on a “palliative care” basis. It is in this context that we can understand McGorry’s anger that funding the National Disability Insurance Scheme (NDIS) might delay the rollout of early intervention services.
McGorry has previously said he sees himself as working towards a “scientific revolution” in the sense that Thomas Kuhn would have seen it — a sudden break from the dominance of one paradigm to that of a new one. Yet the shallowness of McGorry’s approach strikes me as obvious: He may reject parts of the symptom-based DSM model but he has not emerged from the mire of biological reductionism and the use of metaphors crudely appropriated from other branches of medicine.
The real problem afflicting all these attempts to find a way out of the current impasse is that they have failed to accurately diagnose the sources of the crisis. Because psychiatry, like the rest of medicine, is deeply imbued with scientific positivism (that real science is free of social values) and methodological individualism (that social processes are merely the aggregate outcome of individual behaviours), it cannot fully grasp that all health and illness — mental and physical — is both socially embedded and socially constructed. Therefore it cannot critically reflect on its own social nature, its own ideologies and practices that are inextricably bound up with wider social conflicts in their historical contexts.
The reaction to the 1970s crisis of American psychiatry was to use claims about the “reliability” of diagnosis to strengthen the profession’s “scientificity” in appearance but not reality. That model served powerful interests in the psychiatric profession, academia, government bureaucracies, and the pharmaceutical industry, but has unraveled when so many of its claims to help those with mental health problems have been exposed as hollow. A new paradigm that doesn’t simply repeat those flaws cannot be built from above, not by DSM committees nor NIMH directors. It can only be built through the struggles of patients and clinicians for a mental health system driven by quite different social priorities.
Thanks to Melissa Raven for pointing me to the two UHR references.