Psychiatry's new DSM-5 diagnostic manual isn't based on science & shouldn't be trusted
Article first appeared in motherjones.com psychiatrist Allen Frances, chair of the DSM-IV task force interview:
I happen to know this guy who knows a lot about mental-health policy. And, well, okay, he happens to be my father. So my ears perked up recently when my dad mentioned that the DSM-5, the latest in a series of diagnostic manuals soon to be published by the American Psychiatric Association, is something of a disaster.
Indeed, at the end of April, the National Institute of Mental Health (the branch of the NIH that funds mental-health research) took the drastic step of renouncing the latest DSM (short for Diagnostic and Statistical Manual of Mental Disorders) in advance of its publication—renouncing the whole DSM system, really—and replacing it with something called Research Domain Criteria.
"Basically, they said they would no longer use it as a main test in grant requests," explains psychiatrist Allen Frances, who chaired the task force that produced the prior version, DSM-IV (past editions used roman numerals), during the 1990s. "They made it sound like DSM-5 and all the DSMs were invalid, and that we should wait for the new discoveries that were going to come from scientific endeavors."
Frances considers the NIMH's move misguided, but he's no fan of the DSM either. That much is clear from his new book, Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. (The New York Times reviews it here.) Given the current upheaval in psychiatry, and the impending release of the new diagnostic manual, Frances seemed like the man to bring us up to speed on how the DSM got so bloated, and why so many Americans are popping uppers and antidepressants that we don't need.
Mother Jones: What you mean by "saving normal"?
Allen Frances: There's been a rapid diagnostic inflation over the course of the last 35 years, turning problems of everyday life into mental disorders resulting in excessive treatment with medication. Pretty soon everyone's going to have a mental disorder or two or three, and it's time we reconsider how we want to define this and whether the definitions should be in the hands of the drug companies, which is very much what's happened in recent years.
MJ: To what degree has this trend accelerated lately?
AF: We were very, very conservative in doing DSM-IV, which came out in 1994. Despite our efforts to tame diagnostic inflation, the rates of attention deficit disorder (ADD and ADHD) have tripled, the rate of autism increased by almost 40 times. The rate of childhood bipolar disorder increased by 40 times. And the rate of adult bipolar disorder doubled. A lot of this was driven by the drug companies. They had new products on patent—very expensive; it gave them the means and the methods to spread the message to doctors and patients that mental disorders were easily diagnosed, often missed, caused by chemical imbalance, and treated with an expensive pill.
MJ: How do they assert themselves in the DSM process?
AF: They don't assert themselves at all in the DSM process. They have absolutely no contact with anyone. But they wait on the sidelines, and if something can possibly be misused in DSM, it will be misused. The drug companies have marketed heavily to primary-care doctors, who now prescribe 80 percent of psychiatric medication. That is amazing. Most psychiatric diagnosis is being done in seven-minute sessions with doctors who are not very interested or well trained in psychiatry.
MJ: By now, overtreatment of things like ADHD has become a cultural meme. What's an example we might not have heard of?
AF: Well, probably the most overtreated is depression. The DSM system has lumped together really severe depressions that are totally incapacitating and definitely require medication with mild depressions that may just be an expectable reaction to everyday life. The mild depressions have a tremendously high placebo response rate—over 50 percent. The severe depressions don't respond to a placebo.
We have a terrific misallocation of resources in this country, with the severe depressions being very much undertreated; only one-third of people with severe depression get treated for it. At the same time, we're terribly overtreating the mild depressions with medication. Eleven percent of the population takes an antidepressant. In the female 40-to-50 group, it's 23 percent.
Studies show that probably about two-thirds of the people taking an antidepressant don't need it. If you get an antidepressant after a seven-minute visit with a doctor on the worst day of your life, you're going to get better—the placebo response and just time. But if you've taken the pill, you'll assume the pill made you better, and so you'll tend to stay on the pill. So you have lots of people taking medicine they don't need for problems that will take care of themselves, and people who really do need medicine don't have access to treatment.
MJ: Why not?
AF: The budgets have been cut dramatically for mental health. We now have a million psychiatric patients in prison for nuisance crimes because they weren't given adequate care as outpatients and a decent place to live. As Obama put it, it's easier now for someone who's mentally ill to get a gun than to get an outpatient appointment.http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances-saving-normal-dsm-5-controversy
http://www.usatoday.com/story/news/nation/2013/05/12/dsm-psychiatry-mental-disorders/2150819/
http://www.nytimes.com/2013/05/12/opinion/sunday/why-the-fuss-over-the-dsm-5.html?_r=0
Record number: 10.9 million Americans collecting disability:
Newly released data from the Social Security Administration reveal that the number of Americans collecting disability payments is at an all-time high — 10,962,532 — more, to put to put it in perspective, than the total number of people living in Greece.
CNS News writes, “April was the 195th straight month that the number of American workers collecting federal disability payments increased. The last time the number of Americans collecting disability decreased was in January 1997.” But in 1997, that decrease was a miniscule one of just 249 people.
April’s beneficiary figures include a record 8,865,586 disabled workers, 1,936,236 children of disabled workers, and 160,710 spouses of disabled workers.
And as the number of Americans collecting disability continues to increase, the number of full-time workers in the United States continues to decrease.
CNS explains:
In December 1968, 1,295,428 American workers collected disability and, according to the Bureau of Labor Statistics, 65,630,000 worked full-time. Thus, there were about 51 full-time workers for each worker collecting disability. In April 2013, with a record 8,865,586 American workers collecting disability and 116,053,000 working full-time, there were only 13 Americans working full-time for each worker on disability.
Some analysts attempt to explain the increases in disability payments by pointing out that the Baby Boomers are beginning to retire and show health problems.
However, evidence indicates that the increase is instead a result of Congress dramatically expanding the definition of “disabled,” thereby permitting otherwise able-bodied Americans to receive government paychecks for the rest of their lives.
Forbes notes that the significant changes to the disability law date back to Ronald Reagan:
In 1980, Jimmy Carter had signed the Disability Amendments Act of 1980, which encouraged tighter oversight of Social Security disability benefits. Early in Reagan’s first term, the Gipper asked the Social Security Administration to step up enforcement of the new law, leading to the revocation of benefits for over one million people. There was a substantial political backlash to these efforts; as a result, in 1984, Congress unanimously passed the Social Security Disability Benefits Reform Act [SSDBRA].
As Reagan signed the bill, he observed, “It maintains our commitment to treat disabled American citizens fairly and humanely while fulfilling our obligation to the Congress and the American taxpayers to administer the disability program effectively.”
That law allowed applicants’ assessments of their own disabilities to weigh more heavily in the process, and replaced government medical assessments with those of the applicants’ own doctors. Likewise, it loosened the criteria for mental illness.
Data collected by Mark Duggan and Scott Imberman of the National Bureau of Economic Research support the fact that the loosening of the definition of "disability" has been the cause of the increase in the number of "disabled," not more Baby Boomers retiring. The two men published a 43-page paper revealing that just 13 percent of the growth in the receipt of disability benefits in men was a result of aging, and just four percent in women.
Instead, the paper noted that the increase in beneficiaries can be attributed to the relaxation of medical eligibility criteria, which they determined has accounted for a 45 percent in growth for men, and 36 percent growth for women.
http://www.thenewamerican.com/usnews/item/15399-record-number-10-9-million-americans-collecting-disability
Lawyers worry new measure of mental retardation could prompt more executions:
A new standard from the country's leading psychiatric association to diagnose mental retardation could allow courts to execute convicted criminals with IQ scores below 70 more easily, say death penalty lawyers.
The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (APA), is the standard guidebook of psychiatric disorders and is used by clinicians to identify and diagnose psychiatric illnesses.
Each new edition is scrutinized by mental healthcare providers and the pharmaceutical industry for changes in definitions as well as new categories of illnesses. Such shifts can have enormous economic, social and legal implications and often are the subject of controversy.
The fifth edition of the book since it was first published in 1952, or DSM-V, is due to be released May 22. Already it has prompted concern from death penalty lawyers because of the change in the way the manual defines mental illness, or intellectual disability, the new name given in DSM-V.
Earlier editions of the DSM defined mental retardation as an IQ score below 70 accompanied by an inability to meet certain developmental norms, such as bathing regularly or maintaining work. Based on that IQ benchmark, the U.S. Supreme Court ruled in Atkins v. Virginia in 2002 that it is illegal to execute a mentally handicapped person.
But the editors of DSM-V have dropped the 70 IQ score as an indicator of mental retardation and instead recommend that clinicians consider IQ scores while analyzing an individual's behavior to determine if he or she meets the developmental standards.
Making the definition of mental retardation more subjective could prompt more courts to subvert Atkins, said David Dow, a death penalty lawyer in Houston whose client Marvin Wilson was executed in Texas last summer despite his IQ score of 61.
"There are a lot of courts that are hostile to the basic legal doctrine the Atkins case established," Dow said. "When you replace a test that is one part objective, one part subjective with a solely subjective test, it becomes easier for courts that are hostile to the constitutional principle of Atkins to evade that criterion."
While it is illegal under Atkins to execute someone who was diagnosed mentally handicapped, states have the leeway to determine what criteria are used and who makes the diagnosis, said Richard Dieter, executive director of the Death Penalty Information Center. Consequently, states like Texas, Georgia and others have their own statutes outlining criteria to diagnose a convicted criminal as mentally retarded.
From 2002 to 2012, only a quarter of the death row inmates who claimed to have mental retardation were granted stays of execution, according to research by John Blume, director of Cornell University Law School's Death Penalty Project. This included cases that had exhausted all appeals from the time of the Atkins decision to the end of 2012.
"Judges and jurors have stereotypes of what it means to be mentally retarded," Blume said. "There is a problem with people who have lower than 70 IQ scores getting executed in spite of the Atkins ruling, and under the new DSM guidance, that problem is only going to get worse."
Lawyer Susan Orlansky of Feldman Orlansky & Sanders said Texas's individualized statutes are the reason her client, Elroy Chester, will be executed even though he meets the lower-then-70-IQ standard. Chester was convicted in 1998 of fatally shooting a firefighter and confessed to killing four other people in the south Texas town of Port Arthur. He is scheduled to be executed June 12. Orlansky does not think changes in the reliance on IQ scores would impact the decision in Elroy's case.
"Personally, I think if the Texas court system is willing to ignore the DSM-IV, I don't know why they wouldn't be just as willing to ignore the DSM-V," she said.
http://newsandinsight.thomsonreuters.com/Legal/News/ViewNews.aspx?id=77171
More infants born addicted to prescription drugs:
Knoxville, TN- He's less than two weeks old, but he has the telltale signs of a baby in pain: a sore on his chin where he's rubbed the skin raw, along with a scratch on his cheek. He suffers from so many tremors that nurses watch him around the clock in case he starts seizing — or stops breathing.
The baby is one of many infants born dependent on drugs. He is being treated at East Tennessee Children's Hospital in Knoxville, where doctors and nurses are on the front lines fighting the nation's prescription drug epidemic. Drug abuse in the state is ranked among the nation's highest, according to some estimates.
The hospital expects to treat 320 children this year for drug dependence, known as neonatal abstinence syndrome — up from 33 in 2008. Last year, the hospital treated 283.
The statistics include withdrawal from all types of drugs, but doctors attribute prescription drugs for the spike.
"It blew us away," Andrew Pressnell, a nurse at the unit, said of the dramatic increase. "We didn't know what to do."
States across the US have passed laws to crack down on prescription drug abuse, including in the poor, mountainous Appalachian region, where the drugs were easily available as they flowed north from so-called "pill mills" in Florida.
Nationally, the rate of newborns suffering withdrawal, or "neonatal abstinence syndrome," rose 330 percent from 2000 to 2009, according to a study published in the Journal of the American Medical Association last spring.
In some states, it's much worse: In Kentucky, the rate rose 2,400 percent. In Florida, it rose 500 percent between 2004 and 2011, the Sun Sentinel reports. And those figures are likely on the low side, since they don't include infants without immediate symptoms who go home with parents who don't report their drug use.
The US government doesn't track the number of babies born dependent on drugs. A study published last year in the Journal of the American Medical Association found that more than 13,000 infants were affected across the US in 2009.
Tennessee is the first state to track the number of babies born dependent on prescription drugs, said Stephen W. Patrick, a neonatologist at the University of Michigan and one of the authors of the study.
The preferred way to treat drug-dependent babies at the Tennessee hospital is by giving them small doses of an opiate and gradually weaning them off, said Dr. John Buchheit, who heads the neonatology unit. So every few hours, the staff will give the infants morphine to help them get their symptoms of withdrawal under control. They'll be weaned off over a period of either days or weeks, Buchheit said.
Whereas crack babies were more often born to low-income minorities, this epidemic seems to cross racial and socio-economic boundaries. Mothers of babies born with drug issues, they can face losing custody or getting treatment. http://www.csmonitor.com/The-Culture/Family/2013/0513/Surge-in-babies-born-addicted-to-prescription-drugs-worries-hospitals
http://www.livescience.com/22782-more-infants-born-addicted-to-prescription-drugs.html
Ranbaxy USA, a generic drug manufacturer agreed to a $ 500 million dollar settlement:
A team of Venable attorneys represented drug maker Ranbaxy USA, Inc. in a $500 million settlement with the U.S. Department of Justice, marking one of the biggest drug safety deals ever with a generic drug manufacturer.
Ranbaxy USA, the U.S. subsidiary of Indian generic pharmaceutical manufacturer Ranbaxy Laboratories Limited, pleaded guilty today in federal district court in Maryland to charges rooted in the manufacture and distribution of adulterated drugs made in India. Ranbaxy is India's largest generic pharmaceutical company.
The company agreed to pay a criminal penalty of $150 million in addition to another $350 million to resolve civil claims under the False Claims Act and other state laws. Venable partners W. Warren Hamel, Geoffrey Garinther and Winifred Weitsen represented Ranbaxy.
According to the settlement agreement, from April 2003 through September 2010 Ranbaxy allegedly knowingly manufactured, distributed and sold certain drugs that were different strengths and purity and therefore not made according to federal standards. The drugs originated in two of the company's facilities in India. The separate drugs in question were used to treat epilepsy and nerve pain and recalcitrant nodular acne. A third was a broad-spectrum antibiotic.
Hamel is co-chair of the firm’s SEC and white-collar defense practice, and Garinther leads the firm’s litigation division. Weitsen practices in the firm’s SEC and white-collar defense group. Hamel directed a request for comment to the company.
http://legaltimes.typepad.com/blt/2013/05/generic-drug-manufacturer-settles-claims-for-500-million.html