Tag Archives: American Psychiatric Association

DSM 5 Substance Use Disorders: A Concise Summary

DSM_5_2Terry Gorski has a nice summary of substance use disorders in the DSM-5.

Here’s his analysis at the end of the post:

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

 

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Cash, sexual favors and drugs

money-pillsCash, sexual favors and drugs. We’re not talking about a dope house.

Some people (and companies) never learn:

…last week, UK pharma firm GlaxoSmithKline admitted that Chinese doctors were bribed by its execs with cash and sexual favours in return for prescribing the company’s drugs. That coincided with rival AstraZeneca having its Shanghai office raided by police – all of which is jolly inconvenient, as Astra faces the City this week to unveil its interim results.

Some investors ponder whether bribery is a wider problem than has yet emerged, and if Chinese authorities are deliberately targeting foreign firms.

Maybe, but critics of the UK companies also point to GSK’s $3bn fine last year for bribing US doctors, plus Astra’s indictment in Serbia on similar charges, as well as an admission in its annual report about “investigating indications of inappropriate conduct in certain countries, including China”.

Why is this relevant here?

Well, last year GSK, among other things, admitted to illegally marketing Wellbutrin as an addiction treatment. They are a current partner with NIDA on developing a nicotine vaccine.

As for AstraZeneca, they are a new partner with NIDA on developing new addiction treatment medications.

In a related post, Alan Frances argues that congress needs to fix the U. S. mental health system.

On Pharma:

Third, Big Pharma needs to be tamed — just as twenty years ago, Congress tamed Big Tobacco. Drug company marketing consists of nothing more than misleading disease mongering — selling diagnoses to peddle pills to people who don’t need them. If it has the political will to take the following steps, Congress can easily end Pharma’s hijacking of medical care. No more direct-to-consumer advertising of drugs — a privilege Pharma enjoys only in the US. No more misleading marketing to doctors cloaked in the sheep’s clothing of ‘education’. No more financial contributions turning consumer advocacy groups into extenders of company lobbying. No more ‘research’ guided by the marketing efforts to enhance patent life and stretch indications, rather than aiming for real breakthroughs. No more ghost written papers by thought leaders who mouth party line. No more monopoly pricing power because government is prohibited from bargaining. And no more revolving door politicians drifting back and forth from government to cushy Pharma jobs.

On overdoses:

Seventh, Congress should attend to the catastrophe that more people now die from overdoses of prescription than street drugs. High flying prescribers need to be brought to ground with strict monitoring, professional discipline, and public shaming. And real-time computerized control could contain loose drug dispensing. If Visa can put an advance stop on a suspicious $100 purchase, we can develop a proactive check that a prescription makes sense before filling it. Cooperative FDA and DEA scrutiny of drug company marketing practices and distribution methods would reduce the current free availability of lethal narcotics. We are fighting a drug war against the cartels that we cannot possibly win and haven’t yet begun a war against the inappropriate use of prescription drugs that we could not possibly lose.

Also a couple of points on Pharma’s diagnostic fuel.

On the DSM:

First, the diagnostic system in psychiatry is broken and can’t be fixed internally by the American Psychiatric Association — which currently holds the monopoly. DSM-5 has fanned the flames of diagnostic inflation with definitions that turn everyday life problems into mental disorder — harming the misidentified ‘patients’ and costing the economy billions of dollars. Psychiatric diagnosis has become too important (in decisions determining workman’s comp, disability, VA benefits, school services, custody, criminal responsibility, preventive detention, and the ability to adopt a child, fly a plane, or buy a gun) to be left to one small professional association

Psychiatric diagnosis is too much a part of public policy to be left exclusively in the hands of the psychiatrists. Experts in psychiatry have no expertise in how their diagnostic decisions will affect public health, public welfare, the allocation of resources, and the health of the economy. Congress should set up an agency to ensure much more careful vetting of risks and benefits.

On inflated prevelance estimates:

Sixth, Congress should investigate the CDC’s fatally flawed method for determining rates of mental disorder. CDC has a systematic bias toward over-estimating the disorder rates in the healthy and ignoring the needs of the really sick. Its data gathering relies on telephone contacts conducted by lay interviewers who cannot possibly distinguish clinically significant mental disorder from everyday symptoms that are part of the human condition. The wild instability and elasticity of the reported prevalences is proof positive they should be discounted; not taken as credible indication our society is getting sicker. Epidemiological attention should focus instead on the extent and correlates of the more severe mental disorders currently being neglected.

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Intellectual conflicts of interest

DSM_5_2Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

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The DSM-5 is coming

Change is coming, but is it good?

DSM_5_2At its December meeting today, APA’s Board of Trustees approved the final diagnostic categories and criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts. These final diagnoses and descriptive criteria will be available when DSM-5 is completed and published in May 2013.

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Addiction diagnoses to rise

I’ve posted before about problems with the proposed approach to addiction in the DSM-5.

These changes were intended to clear up language problems, specifically the conflation of dependence and addiction leading to “false positives” for addiction. Looks like the DSM-5 is causing its own language problems before it’s even adopted. [emphasis mine]

Many scholars believe that the new manual will increase addiction rates. A study by Australian researchers found, for example, that about 60 percent more people would be considered addicted to alcohol under the new manual’s standards. Association officials expressed doubt, however, that the expanded addiction definitions would sharply increase the number of new patients, and they said that identifying abusers sooner could prevent serious complications and expensive hospitalizations.

Further, I’m pretty skeptical of the suggestion that the current abuse diagnostic category constitutes a medical illness requiring any kind of medical treatment, and they are looking forward to the new criteria being more inclusive and being classified as having form of addiction?

The article demonstrates that the inevitable slide into viewing low-severity AOD problems as the first stage of addiction:

“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”

On top of this, conflicts of interest are being exposed. It’s pretty clear that this would be a major boon for drug companies, particularly with the Affordable Care Act simultaneously increasing access to healthcare for people with AOD problems and increasing physician responsibility to treat AOD problems that they are poorly equipped to address.

Some critics of the new manual have said that it has been tainted by researchers’ ties to pharmaceutical companies.

“The ties between the D.S.M. panel members and the pharmaceutical industry are so extensive that there is the real risk of corrupting the public health mission of the manual,” said Dr. Lisa Cosgrove, a fellow at the Edmond J. Safra Center for Ethics at Harvard, who published a study in March that said two-thirds of the manual’s advisory task force members reported ties to the pharmaceutical industry or other financial conflicts of interest.

Dr. Scully, the association’s chief, said the group had required researchers involved with writing the manual to disclose more about financial conflicts of interest than was previously required.

Dr. O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction.

He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction.

“I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.

Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, in Bethesda, Md., described opposition from many researchers to adding “craving” as a symptom of addiction. He added that he quit the group working on the addiction chapter partly out of frustration with what he described as a lack of scientific basis in the decision making.

“The more people diagnosed with cravings,” Dr. Moss said, “the more sales of anticraving drugs like Vivitrol or naltrexone.”

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Even more on the DSM-V

The Fix follows up on the previous piece about the coming changes in the DSM-V.

The writer captures my concerns:

I don’t foresee any negative results from dropping those two misguided terms. (abuse and dependence) But what does concern me is the fact that rather than still having two separate and distinct conditions—one, a short-term, self-limiting disorder and the other a condition likely to be chronic and relapsing—there will now be only one way to have a drug problem. The gradations of the condition will likely be delineated as “mild,” “moderate” or “severe” substance use disorder. While the word “addictive” will appear in the heading that labels the overall category, it will not figure in the diagnoses themselves. For example, you could have mild, moderate or severe opioid dependence disorder or gambling disorder. (So far, gambling is the only behavioral addiction to make the DSM cut.)

But this elision of the problems formerly known as abuse and dependence will, I fear, cause major problems for many people, especially teenagers and young adults. What it means, in a worst-case scenario, is that every college binge drinker will be at risk for being labeled an alcoholic and every high school stoner, an addict.

It’s unfortunate that the author trots out gross stereotypes and caricatures in paragraphs 9 through 12. She falls into the cognitive errors that Kathryn Shultz describes so well at 9:59 through 11:17 of this great talk:

Good thing we don’t use Jayson Blair, Stephen Glass, Jack Kelley and partisan medial outlets to slander writers in general 😉

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