Thursday, February 18, 2010

DSM V and Mood Disorders, Part I -- What's at Stake

Earlier this month, the American Psychiatric Association released the long awaited proposed revision of their Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  It is available now for public comment, with an anticipated publication date for the final version in May 2013.  To call this the Bible of Mental Illness is to overestimate the significance of the Bible.


The DSM was first written to give clinicians and researchers a common vocabulary and a common understanding of the various diagnoses of mental illness.  John McManamy has related this history on his blog Knowledge is Necessity.  I refer you to his thorough account, found in the links at the bottom of his post. -- [Hey, John -- I recognized your image for "Few Surprises."  It was one that I considered for this post!]

The way the DSM works always reminds me of a Chinese menu.  For example, if you have one symptom from Column A and at least five from columns A and B, for over two weeks, you have Major Depressive Disorder.  You can upgrade your core diagnosis with specials offered alongside the basic menu.  These lists of symptoms provide a common vocabulary and simplify diagnosis, so that family practitioners commonly diagnose depression and prescribe antidepressants, without referral to psychiatrists.  This practice provides a boon to the pharmaceutical industry, which markets heavily to family practitioners.  If patients had to see a psychiatrist to get a prescription, fewer people would take antidepressants, since there is greater stigma attached to treatment by a psychiatrist, psychiatrists are in short supply in many parts of the country anyway, and health insurance plans provide inadequate coverage for psychiatric care. So family practitioners prescribing for depression sells more antidepressants.  Big Pharma wants to keep the DSM simple.

Over time, even as therapists have become more eclectic in their therapies, the sequence of DSMs has more narrowly defined the illnesses which therapists treat, adding more specificity.  The DSM gives a numerical identifier for each diagnosis, along with decimal points after the numbers to indicate variations and severity.  Health insurance companies rely on the DSM to determine coverage.  If you don't have a number, you don't get reimbursed.  But they have become concerned about the multiplication of diagnoses, raising the number of claims.  Health insurance companies want to limit the number of diagnoses and limit the number of people diagnosed.

Meanwhile, mood disorders (major depression and bipolar) represent 9.5% of the adult population in the United States in any given year.  18.1% of the adult population are diagnosed with anxiety disorders.  There is considerable overlap between these two groups.  This is a pretty big market for Big Phama, and considerable expense for the health insurance industry, notwithstanding the extreme limitations on coverage.  So the drug and health insurance industries are major stake holders in the revision of the DSM.

Given my own diagnosis, my interest and maybe yours falls in the mood disorder area.  The DSM V has the opportunity (and the charge) to incorporate changes in what we have learned about mood disorders over the last sixteen years.  One example would be the gender and cultural differences in how depression presents, which could alter that list of nine options from Columns A and B.  Another example is the results from the ongoing "chemistry experiment."  People, all of whom fit  the category of major depression, respond differently to treatment by antidepressants, depending on a more precise differentiation of their symptom profiles.  In this case, incorporation of new knowledge could improve prescribing practices and save lives.

Add patients to the list of stake holders in the revision of the DSM, along side the pharmaceutical and health insurance industries.  Guess who has a voice in the deliberations?

So what changes in the diagnostic criteria for mood disorders have been made from the DSM IV (publication date 1994) to the proposed DSM V (2010)?  Short answer -- practically none.

Okay, a couple changes.  The criteria acknowledge that children manifest depression differently than adults.  But among adults, white women continue to be the gold standard.

There is also a new diagnosis for "mixed anxiety depression."  This category was proposed for further study in the DSM IV.  It provides that all important number to those who fall just short of a diagnosis of both depression and anxiety, allowing the diagnostician to add the two scores together.

The price that patients will pay for the continued status quo is a continued cursory screening for Bipolar and Bipolar II ("Are you manic?" -- yes, that's what she said), followed by a quick prescription for antidepressants (Prozac by doctors who are paying attention to cost, Zoloft by those who are cozy with the sales rep), followed by dangerous side effects, and the triggering of mania or hypomania, followed by an acceleration of cycling, followed by out of control mental illness and disability.

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide.  That's pretty much what I said in my last paragraph.  And what I will say if I ever testify at a class action suit.

Get it?  People's lives are at stake.  That is "What's at Stake."

Okay, there is one significant change.  Bipolar II is diagnosed when Major Depression is accompanied by one hypomanic episode.  [Think "baby mania."]  The proposed DSM V does expand the criteria for hypomania.

Here is the text from the DSM IV: 

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.

And the proposed revision: 

Note: A full manic or hypomanic episode emerging during antidepressant treatment (medication, ECT etc) and persisting beyond the physiological effect of that treatment is sufficient evidence for a manic or a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following antidepressant use) are not taken as sufficient for diagnosis of a manic/hypomanic episode.

This is a significant revision and supported by clinical experience.  Indeed, the most frequent path to diagnosis of Bipolar II goes through the path of misdiagnosis.  They figure out you have Bipolar II after you take antidepressants and all hell breaks loose.

What is wrong with this picture?

And why does the DSM V preserve this devastation of misdiagnosis?

See above, the identified stake holders.  "Guess who has a voice in the deliberations?"

And if you want a more thorough analysis of why I am so outraged, or if you are curious about other sections of the book as well, do check out John McManamy's work.

Next week:  Where I think we are going and how I think we will get there.

Permission is granted to copy, distribute and/or modify the photo
above under the terms of the GNU Free Documentation License

10 comments:

  1. Dear Ms. Goodfellow:

    There is another change that you may not have noticed (or else I missed your comments on it); i.e., dropping the "bereavement exclusion" from the criteria for major depressive episode. Both Dr. Sidney Zisook and I support this proposal, and if you care to see why, you may read our piece on the Psychiatric Times website [see
    "DSM5 Criteria Won't Medicalize Grief if Clinicians Understand Grief."]

    On the matter of bipolar disorder and antidepressants, I share your concern about inappropriate use of these medications in bipolar disorder, where, in general, I believe they do more harm than good. Of course, the DSM is not designed as a treatment manual, but if it increases the net number of folks diagnosed with BP II disorder, it may have the unintended effect of increasing antidepressant prescribing in this vulnerable population (most of which prescribing is not done by psychiatrists but by primary care doctors with little training in dx. or treatment of BP disorder).

    Sincerely, Ronald Pies MD

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  2. Dear Dr. Pies,

    First I thank you for making your comments. My blog is not intended for my personal writing therapy, but rather to educate (and provoke!) So I am delighted and honored when professionals engage the conversation.

    Second, I cop to the bag-over-the-head syndrome. "It wasn't about me." I suppose I also missed the elimination of the bereavement exclusion because my focus was on the new version, which simply excludes it. I missed what was missing.

    I had an aha! moment reading your own article. [Readers, find it at http://www.psychiatrictimes.com/display-old/article/10168/1523978. It is indeed readable. Briefly (very briefly) -- the bereavement exclusion in the DSM IV says that if you meet the criteria for MDD, but somebody died within the last two months, you don't have MDD, because the symptoms could be explained by the normal grieving process. Doctors Pies and Zisook (the latter referenced in the DSM V on this issue) make the point that bereaved persons get MDD, too, and shouldn't have to wait another two months for treatment because of an external event.

    My aha! was that the DSM IV manifests here the tendency of others to judge whether there is a reason "good enough" for one to feel depressed. It says that the death of a loved one is good enough. But being homeless isn't? You don't get treated if the clinician can understand why you might be depressed?

    However, your last suggestion, "Finally, we believe it is time for the DSM to look more carefully at phenomenology—the contents of the patient’s felt experience—rather than relying almost entirely on behavioral and symptomatic check-lists" calls for a clinical experience that most of us earnestly desire from our diagnosticians, but experience as coming out of fantasy land. In my own case, my plan's reimbursement rates are so low that in a city with 88 psychiatrists, only one practice is in-network -- because they have worked out how to do a fifteen minute intake interview. You are calling for a whole new culture, which most patients would applaud. But we are not holding our breaths.

    Thanks again for taking your time for Prozac Monologues.

    Willa Goodfellow

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  3. Bravo, Willa! Brilliant analysis. I love this line:

    "The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience."

    Encore ...

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  4. Thank you for this. I'm stuck in the anti-depressant is not working for me. After a year of trying to convince my GP. I've decided to see a psychiatrist. I wish I went there first. But, oh well. What's a couple of years of the crazies gonna do? Thoughts of gruesome suicide... that's what.

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  5. Dear Anonymous --

    I didn't manage to cram into this post that psychiatrists are often no better educated about this issue than family practitioners. I recommend that you go to that appointment with some information to share that you present in the form of questions, "I hear that some people with unipolar depression who have trouble with antidepressants do better with a mood stabilizer. Do you think Lamictal would help me?" See the bottom of the post at http://prozacmonologues.blogspot.com/2010/01/prozac-is-talking-anybody-listening.html for more.

    Best wishes -- Willa

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  6. Thanks for the astute remarks on my article, and on the issue of bereavement, Ms. Goodfellow. I think your critique is very much in line with mine and Dr. Zisook's.

    As for "phenomenology"--yes, I understand this may sound like pie (or Pies) in the sky, in today's McDonaldized health care system. But it is still a standard we mental health clinicians should strive for! And there are some of us out there who still sit with the patient for that classical "50 minute hour."

    Sadly, health care is so hard to come by these days, we can provide our "best" to only a small percentage of those who could benefit. --Best regards, Ron Pies MD

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  7. Bipolar disorder is a severe and complicated mental illness. Many doctors are unable or unwilling to diagnose bipolar disorder in children and young teens. It is important to get help and recognize the different treatment options available. The Silver Hill Hospital website has some helpful information and resources about different adolescent residential programs.

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  8. Bridgette -- Thanks for the reference. I am impressed by what I see at Silver Hill's website, especially the page on values and the emphasis on Dialectical Behavior Therapy. I got a bit of exposure to DBT in the Peer to Peer class (sponsored by NAMI). I find even the little bit helpful, and hope to learn more.

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  9. We all have views and opinions on types of mood disorders and as we can see, people with these kinds of illnesses are increasing because the levels of stressful activities are increasing as well. And today, not only psychiatrists but the pharmaceutical companies are also formulating medicines, carefully measured through FT NIR systems for these illnesses be treated.

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