NIMH vs DSM 5: No One Wins, Patients Lose


The flat out rejection of DSM-5 by National Institute of Mental Health is a sad moment for mental health--and an unsafe one for our patients. The APA and NIMH are both letting us down, failing to be safe custodians for the mental health needs of our country.

The flat out rejection of DSM-5 by National Institute of Mental Health is a sad moment for mental health--and an unsafe one for our patients. The APA and NIMH are both letting us down, failing to be safe custodians for the mental health needs of our country. 

DSM-5 certainly deserves rejecting. It offers a reckless hodgepodge of new diagnoses that will misidentify normals and subject them to unnecessary treatment and stigma.

The NIMH director may have hammered the nail in the DSM-5 coffin when he so harshly criticized its lack of validity.

But the NIMH statement went very far overboard with its implied promise that it would soon find a better way of sorting, understanding, and treating mental disorders. The media and internet are now alive with celebrations of this NiMH 'kill shot'. There are chortlings that DSM-5 is dead on arrival and will perhaps take psychiatry down along with it.

This is misleading and dangerous stuff that is bad for the patients both institutions are meant to serve.  

NIMH has gone wrong now in the very same way that DSM-5 has gone wrong in the past- making impossible to keep promises. The new NIMH research agenda is necessary and highly desirable-- it makes sense to target simpler symptoms rather than complex DSM syndromes, especially since so far we have come up empty. And the new plan will further, and be furthered, by the big, new Obama investment in brain research. But the likely payoff is being wildly oversold. There is no easy solution to what is in fact an almost impossibly complex research problem.

Isaac Newton said it best almost 250 years ago; "I can calculate the motions of the heavens, but not the madness of men." Figuring out how the universe works is simple stuff compared to figuring out what causes schizophrenia. The ineffable complexity of brain functioning has defeated past DSM hopes and will frustrate even the best NIMH efforts.

Progress in understanding mental disorders will necessarily be slow, retail, and painstaking-- with no grand slam home runs, just occasional singles, no walks, and lots of strikeouts. No sweeping explanations-- no Newtons, or Darwins, or Einsteins.

Experience teaches that there is very little low hanging fruit when you try to translate the results of exciting basic science into meaningful clinical advances. This is true in all of medicine, not just psychiatry. We have been fighting the war on cancer for 40 years and are still losing most of the battles.

If it has been so hard to figure out how simple breast tissue goes awry to become cancerous, imagine how many orders of magnitude more difficult will it be to eventually understand the hundreds or thousands of ways neurons can misconnect to cause what we now call schizophrenia.

We have learned many remarkable things about how our bodies work. But it is much easier to understand normal functioning than to figure out all the ways it can become abnormal.The NIMH effort may (or may not) be the wave of the future, but most certainly, it can have no impact whatever on the present.   

Meanwhile, APA and NIMH are both ignoring the very real crisis of mental health misallocation in this country.  While devoting far too many resources to over-treating "the worried well," we have badly shortchanged the severely ill who desperately need and very much benefit from our help. Only one third of severely depressed patients get any care and we have one million psychiatric patients languishing in prisons because they had insufficient access to care and housing in the community. As President Obama put it, it is now easier for the mentally ill to buy a gun than to get an outpatient appointment- tragic on both counts.

APA and NIMH are both on the sidelines, doing nothing to help restore humane and effective care for those who most need it. DSM-5 introduces frivolous new diagnosis that will distract attention and resources from the real psychiatric problems currently being neglected. NIMH has turned itself almost exclusively into a high power brain research institute that feels almost no responsibility for how patients are treated or mistreated in the here and now.     

We are spending fortunes on unnecessary drugs for the worried well while slashing budgets for the care of the really sick. A meta-analytic comparison of treatment effectiveness across medical specialties showed that psychiatry was well above average. But we have to provide the treatment to those who really need and can benefit from it.  

With all its well recognized limitations, well done psychiatric diagnosis remains essential to effective psychiatric care. Diagnosis is reliable enough when it is targeted to real psychiatric disorders, is done by well trained clinicians, and is not provided prematurely to provide a code for insurance reimbursement.

The single biggest cause of diagnostic inflation and unnecessary treatment is that 80% of prescriptions for psychiatric drugs are written by primary care doctors who have insufficient training and  too little time in their seven minute visits to be accurate- and when both doctor and patient are unduly influenced by saturation drug marketing.

So what is a patient or potential patient or parent to make of the confusing struggle between NIMH and DSM-5 debacle?

My advice is to ignore it. Don't lose faith in psychiatry, but don't accept psychiatric diagnosis or treatment on faith- particularly if it is given after a brief visit with someone who barely knows you. Be informed. Ask lots of questions. Expect reasonable answers. If you don't get them, seek second, third, even fourth opinions until you do.

A psychiatric diagnosis is a milestone in a person's life. Done well, an accurate diagnosis is the beginning of increased self understanding and a launch to effective treatment and a better future. Done poorly it can be a lingering disaster. Getting it right deserves the kind of care and patience exercised in choosing a spouse or a house.

Remember that psychiatry is neither all good or all bad. Like most of medicine, it all depends on how well it is done.    

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