Psychiatrists Revise the Book of Human Woes

A recent piece of New York Times investigative reporting—Psychiatrists Revising the Book of Human Troubles—discloses private meetings of panels composed of psychiatrists convened for the express purpose of revising the Diagnostic and Statistical Manual of Mental Disorders—the book that contains criteria for classifying and diagnosing psychiatric illness.

At issue is that all participants were mandated to sign nondisclosure agreements forbidding them to “make deals to write casebooks or engage in other projects based on the deliberations without working through the (American Psychiatric) association.” In short, they have been forbidden to disclose deliberations while the DSM-V revision is being drafted. Participants also had to agree “to limit their income from drug makers and other sources to $10,000 a year for the duration of the job.”

Judging from comments appended to the article, the outcry against these proceedings has been sharply critical. Special interest groups have a stake in the wording of specific diagnoses, and their representatives heatedly debate whether some disorders actually merit classification as mental illness. It seems that everyone—from individual patients to pharmaceutical firms to mental health professionals to third-party payers—has a stake in the final wording of the DSM-V.

As a practicing clinician, I find it particularly disturbing to read that the list of psychiatric diagnoses has almost tripled since publication of the first DSM in 1952. Undoubtedly, formulation of some of the latest diagnoses has been driven by the pharmaceutical industry, which seeks to market more recently developed psychotropic medications to treat perceived ailments and disorders. Yet other diagnoses—such as schizophrenia, bipolar disorder and autism—appear to be valid in that they provide labels for clinical syndromes that medical practitioners have documented for decades in daily practice.

More and more, modern medical practice is evidence-based, relying on scientific research. Any scientist worth his salt knows that the first step in solving a problem—in this case effectively treating a mental disorder—is to define it. Applying a diagnostic label paves the way for the patient to receive treatment, whether that treatment is pharmacologic or psychotherapeutic. The same label also allows clinicians to be reimbursed for their services by third-party payers.

Problems arise when everyone enters the fray to voice an opinion. At core we are all driven by special interests. In the healthcare arena, suffering patients seek a cure; clinicians expect remuneration for their services; pharmaceutical companies desire to market their drugs; third-party payers want to maximize profits by paying out on as few claims as possible.

As one who has spent his professional career evaluating and treating patients—mostly children and adolescents, many of whom exhibit problematic behaviors—my first priority has always been to search for ways to help better their lives. Sometimes that has meant behavioral intervention, sometimes counseling or psychotherapy, sometimes medication. Obviously, in order to be able to continue to serve my patients, I need to be reimbursed for my services. And while I think that certain categories of mental illness are over-diagnosed in our modern psychiatric paradigm, I applaud the comment of tntgraham, who writes that “there are many dedicated men and women neuroscientists, clinicians and researchers who are continuing to try to better understand disorders of mental life and trying to improve the lives of people who suffer from mental illness.”

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