DSM-V and Some New Diagnoses

Just a little piece on the DSM-V update at the Los Angeles Times. Written by Christopher Lane, author of the fascinating Shyness: How Normal Behavior Became a Sickness. Lane has done extensive research into the processes involved in the creation of the DSM. Many of them were quite arbitrary. Here’s a quote from the Times article:

Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmaceutical companies and agencies that regulate drugs. Because large numbers of countries, including the United States, treat the DSM as gospel, it’s no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world.

Behind the dispute about transparency is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full-scale mental illnesses in their own right. Also, because so many participants in the process of defining new disorders have ties to pharmaceutical companies, some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.

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Prescription Privileges and Standard of Care

It sometimes appears that there’s nothing left to say on this topic — yet there’s occasionally a new wrinkle.

One issue that comes up is whether having a client go for a medication consult is what’s called “standard of care”. Essentially, “standard of care” means that there is some consensus within the profession that minimally competent practice would include the action, in this case a medication consult. In other words, you’d better follow this procedure or open oneself to vulnerability to lawsuits.

Who determines standard of care? Currently when someone comes to us with major depression we are supposed to refer them to a psychiatrist. But how about these scenario? A woman is filled with anxiety due to financial troubles. Is the standard of care to refer to a financial advisor? A man comes with deep concerns about his religion. Is the standard of care to refer to a priest? Are we committing malpractice by exploring such questions without referring?

As usual, it depends. Psychologists, when working as psychotherapists, are duty bound to explore the psychological implications of their clients concerns, first and foremost. It may be that concurrently — or after such concerns are thoroughly explored — a psychologist should consider referring to somone with another specialty, be that a psychiatrist, member of the clergy, or financial counselor.

Psychologists are not giving up their area of expertise by occasionally referring out. Good clinical work often involves consulting other professionals, and always includes knowing the boundaries of one’s competence. On the other hand, referring out in a knee-jerk fashion probably is not good clinical judgment and may even speak to some laziness on a clinician’s part.

Kalea Chapman, Psy.D.

Pharmaceutical Sales 2007: Antipsychotics For Sale

Out of the $663 billion sales of pharmaceuticals in 2007, the sale of psychotropic medications was not that high: 3 percent for antipsychotics, 3 percent for antidepressants. Yet if you look at the top ten best-selling drugs, three of them are antipsychotics. The source is IMS health, who describe themselves:

IMS is the one global source for pharmaceutical market intelligence, providing critical information, analysis and services that drive decisions and shape strategies.

Clinical Psychology and Psychiatry: A Closer Look quotes the IMS statistics and adds these observations:

Antipsychotics were the sixth best selling class of medications globally in 2007, according to IMS Health. They raked in a cool $20.7 billion, an increase of 10.7% from 2006. Thank God we are doing a better job of overrecognizing, er, appropriately treating bipolar disorder. Antidepressants were #7, at $19.7 billion, down nearly seven percent. This does not appear to be due to declining prescriptions. Blame generics, not decreased prescriptions for the lower numbers. With Cymbalta, Lilly has shown that new antidepressants don’t have to be anything special, so it would behoove other companies to release other run of the mill antidepressants, attach a comical, er, highly educational marketing campaign such as Depression Hurts, then watch the money roll in. Just some free advice.

It was the author of that website (Clinical Psych) that proposed a National Bipolar Unawareness Week. An humorous take on the overdiagnosis of manic depression.

Time Story on the Medicated Army

Fighting low morale with SSRIs. The gist of the story in last week’s Time magazine is that the army is using SSRIs to combat battle fatigue and low morale. A disturbing conclusion that one might take away from the article is that the use of SSRIs, used to extend deployments, might actually contribute to the high incidence of PTSD — arguably a more damaging condition that depression. There is a high rate of PTSD among troops who have been deployed two or three or more times to Afghanistan or Iraq.

A new deployment model: As one army source commented this changes the model of how long troops can be deployed:

“Colonel Joseph Horam says antidepressants have made “a striking difference” in the way troops are treated in war….In the Persian Gulf War, we didn’t have these medications, so our basic philosophy was ‘three hots and a cot'” — giving stressed troops a little rest and relaxation to see if they improved. “If they didn’t get better right away, they’d need to head to the rear and probably out of theater.” But in his most recent stint in Baghdad in 2006, he treated a soldier who guarded Iraqi detainees. “He was distraught while he was having high-level interactions with detainees, having emotional confrontations with them — and carrying weapons,” Horam says. “But he was part of a highly trained team, and we didn’t want to lose him. So we put him on an SSRI, and within a week, he was a new person, and we got him back to full duty.

Treating PTSD with SSRIs? Since a large number of veterans are being diagnosed with PTSD. The piece raises the question about whether SSRIs are being used to treat that disorder. This is an important question since SSRIs have never been shown to be effective in treating PTSD. They might function as a band-aid at best.

Chris LeJeune could have told them that. When he returned home in May 2004, he remained on clonazepam and other drugs. He became one of 300,000 Americans who served in Iraq and Afghanistan and suffer from PTSD or depression. “But PTSD isn’t fixed by taking pills — it’s just numbed,” he claims now. “And I felt like I was drugged all the time.” So a year ago, he simply stopped taking them.

Suicide and SSRIs. And the article also examines a possible link between suicide and the use of SSRIs, although it’s careful to note that it’s not clear that this is a direct link (i.e. causal). With antidepressants being handed out like candy, the statistic may not be as surprising as they appear at first glance, but they certainly give pause:

Nearly 40% of Army suicide victims in 2006 and 2007 took psychotropic drugs — overwhelmingly, selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft.

Check out the story here. The graphic is priceless.

Kalea Chapman, Psy.D.

Sleeping Pills: More Fun From Big Pharma

Everyone Needs Therapy (April 6) has an interesting post commenting on a Wall Street Journal article on, you guessed it, sleeping pills. Not surprisingly, they can have some unintended effects. Since the usual suspects here are SSRIs and atypical antipsychotics — here’s a look at sleeping pills. More fun from Big Pharma.

Kalea Chapman, Psy.D.

Comfortably Numb by Charles Barber: A Review

From Biological Psychiatry to Aplysia californica. Recently read Charles Barber’s Comfortably Numb: How Psychiatry is Medicating a Nation, a book noted elsewhere on this blog. It’s a compelling read that covers a lot of ground — the rise of Big Pharma and what he calls “The Triumph of Biological Psychiatry” (a history of how psychiatry shifted from a focus on Freudianism to a focus on medication), a section on psychotherapy that leans pretty heavily in favor of cognitive-behavioral therapy, and a curious chapter on the work of Eric Kandel, winner of the 2000 Nobel Prize in physiology or medicine.

Big Pharma. Barber manages to trot out numerous horror stories about the behavior of Big Pharma — the weakness of the FDA, the number of articles ghostwritten for American medical journals by writers hired by Big Pharma, that one in five visits to a psychiatrist leads to the prescription of an antipsychotic (New York Times, June 6, 2006) and plenty more. The chapter entitled “The Commerce of Mood” is particularly enlightening about the power of the pharmaceutical industry.

A history of psychiatry. Barber covers a jolting swing of the pendulum in psychiatry, from an almost complete embrace of Freudianism to an equally complete embrace of the use psychotropic medication. Freud’s ideas flourished after the Second World War. Barber asserts that it was the discovery of Thorazine in 1952, followed by that of Valium in the 1960s that signaled the death of psychotherapeutic psychiatry. (He provides an amusing Freudian conception of what today we’d call Post-traumatic Stress Disorder (PTSD). “…the conditions of war caused soldiers to regress to an infantile condition, whereby commanding officers became father or older brother figures” [p. 71]). Thorazine literally transformed asylums within days, a shift from mayhem, to something a more manageable. And Valium came at just the right time, social pressures on happiness were increasing, and here was a drug that eased anxiety. Here was perhaps the beginning of what Barber terms “emotional entitlement”. Continue reading “Comfortably Numb by Charles Barber: A Review”

Bipolar Disorder: Overdiagnosed?

Two indicators: Research and practice. Well a new study seems to indicate that overdiagnosis is the order of the day. Furious Seasons has two stories on this topic, April 6 and 7, both quotes are straight from Furious Seasons.

Clinical Psychology and Psychiatry, advocating a Bipolar Overawareness Week, has an extensive treatment of the topic, with some great quotes from David Healy, an Abilify video, and some wise words about the significance of getting a diagnosis, from The Last Psychiatrist.

To top it off, John Grohol at Word of Psychology covers the study and links to a first-person account of being diagnosed. It’s called To Hell and Back published in the Daily Kansan. Here’s a quote from the initial study’s author, Mark Zimmerman:

Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive.’ He continues, ‘This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder.

Zimmerman concludes, ‘The results of this study suggest that bipolar disorder is being overdiagnosed and we recommend that clinicians use a standardized, validated method in diagnosing bipolar disorder. Continue reading “Bipolar Disorder: Overdiagnosed?”