Updates to psychiatric guide spur controversy

A panel of psychiatrists charged with updating the reference manual used to diagnose mental illness in the United States has abandoned controversial plans to add new diagnoses for people with mild psychosis and those who are simultaneously anxious and sad — even as the committee has left in place a host of other proposals that have ignited fierce criticism from professionals in the field.

The American Psychiatric Association revealed last week that it will scrap plans to add two new conditions to the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 — the massive tome considered the bible of modern psychiatry.

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The first condition, “attenuated psychosis risk,” was meant to identify young people in danger of developing a full-blown psychotic disorder as they get older. But many psychiatrists complained that scant evidence exists that the symptoms — for instance, occasional mild hallucinations or delusional thinking — reliably predict later psychosis. And they warned that a diagnosis could prompt doctors to needlessly treat many youngsters with powerful antipsychotic drugs that have harmful side effects.

More research needed

Also gone is a proposed category for “mixed anxiety depressive disorder” that critics charged could label the challenges of everyday life a mental condition. Both categories will instead be put in a section of the DSM-5 for conditions requiring further research.

The modifications were among a series unveiled Wednesday that will be open to a third and final round of public comment lasting six weeks, through June 15. The 162-member group charged with revising the DSM-5 could make further changes in the next several months since the final draft is not due to the printer until the end of the year, with publication scheduled for May of next year.

David Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and chairman of the current task force, said the latest tweaks showed the committee was responding to outside opinion and comment.

“We have not made decisions ahead of time,” he said. “I am spending 24-7 with 160 colleagues trying to do the best we can to listen to everybody.”

But the years-long drafting process has been dogged by delays and allegations of disorganization and secrecy. That process looms large over the psychiatric association as it opened its annual conference in Philadelphia on Saturday.

The stakes are heightened by the outsize role the DSM plays in American society. Used by medical professionals to assign patients diagnostic codes based on their symptoms, the DSM’s wording can affect what treatments a person is prescribed, whether their health insurance pays for it, what school and social services they are entitled to, and how long they can be committed by a court.

Allen J. Frances, chairman of the committee that updated the current, fourth edition of the DSM in the 1990s, and among the most prominent critics of the latest effort, also pointed to aggressive tactics adopted by pharmaceutical companies in recent years. Eager to identify new customers, he said, they were quick to capi­tal­ize on seemingly minor expansions made to categories in the current DSM by directly marketing to the public or to primary care doctors and OB-GYNs — who, while less trained in the nuances of mental illness, prescribe the largest share of many psychiatric medications, including antidepressants.

Echoing other critics, he complained of a raft of proposals still on the table that could unduly pathologize and stigmatize everyone from baby boomers experiencing “senior moments” — who could be classified as having a new “minor neurocognitive disorder” — to fraternity boys engaged in a series of weekend benders — who could fall under an expanded category of “addiction.”

“The implications are way beyond anything you can imagine. . . . Add a new symptom and suddenly tens of millions of people who don’t currently qualify for a diagnosis will wake up with it and will see an ad on television or in a magazine encouraging them to get medicine,” said Frances.

“And instead of trying to contain this issue, the DSM-5 will open the floodgates even wider.”

Rationale questioned

Kupfer countered that the task force is being “very careful of this issue of unintended consequences” and plans to set up the DSM-5 as a “living document” that will be continuously modified as needed in the coming years.

He pointed to a compromise also proposed Wednesday to address another tempest that has been brewing over the task force’s original plan to eliminate a “bereavement exclusion” for depression in the current DSM.

The exclusion holds that people mourning a death cannot be diagnosed as suffering a major depressive episode if they have been grieving for less than two months or if their symptoms are limited — for example, they experience guilt over the death but not a general sense of worthlessness.

Members of the task force had said they worried the exclusion could prevent individuals who do suffer genuine, severe depression shortly after a loss or death from getting timely treatment. But researchers such as Jerome Wakefield, a professor at New York University who specializes in depressive disorders, have published findings concluding there was insufficient evidence to warrant removing the exclusion.

Rather than jettisoning it altogether, the task force now proposes to include a version of it in a footnote that would explain that the normal response to significant loss, including not just bereavement but financial ruin and natural disaster, can resemble depression. The footnote then lists specific symptoms that would suggest genuine depression.

Wakefield partly praised the idea, stating that “in a sense the footnote is actually more valid than the bereavement exclusion because it recognizes that people can have these symptoms under a variety of conditions. And that could be a tremendous advantage in terms of eliminating a lot of false diagnoses.”

But he also worried that “putting it in a footnote has the danger that it will be ignored. . . . I still don’t understand the rationale."

 
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