DSM kerfuffle, Part the First

This month the fifth edition of the of the Diagnostic and Statistical Manual of Mental Disorders (DSM) came out, and the release is generating more press than one might expect from the publication of a thick, dry tome that resides mostly in the offices of psychiatrists, psychologists, and insurance companies. Typically, given the media's weakness for controversy, the coverage tends to focus on the controversies surrounding the new DSM.

This piece at The Guardian covers some of the issues, in particular the objections of the British psychological establishment to the latest DSM. In anticipation of the publication of the new DSM the Division of Clinical Psychology (DCP),  part of the British Psychological Society, released a statement detailing the members' objections to the new DSM. I want to talk today about those objections. Tomorrow, time willing, I will address the concerns from within the psychiatric community, and discuss a maddening and ill-reasoned screed from a psychiatrist who worked on the previous edition of the DSM. For now, let's deal with the psychologists.
But before launching into full WTF mode, I do want to acknowledge that there are some valid criticisms to be made. Some of these criticisms involve this particular edition of the manual, which does indeed show a disturbing tendency toward turning some behaviors and conditions (such as normal grief or some types of childhood misbehavior) into illnesses or syndromes that will require medical intervention (for which, read "drugs").

In addition, the entire question of what, exactly, psychiatry deals with is never really made clear. This goes back to an issue I have discussed before: mental illness remains mostly a mystery to us, and we have no biologically based tests that can determine definitively that someone has, for example, depression or autism. Which is only to say that the science of treating ill minds lags well behind the science of treating ill or damaged bodies (and unfortunately even the medical treatment of bodies is in many cases woefully crude, as in the treatment of most cancers). So the new DSM gives us sets of symptoms, which are judged subjectively, that are used to assign illnesses that may not exist. The existence of a mental illness is determined by committee and consensus, not by actual science. But this is not a new criticism; in this the new DSM functions much like the previous DSM. This is a general critique that should be leveled not just at the DSM but more broadly at psychiatry AND psychology. I include psychology since, as I'll address, psychology is not any better than psychiatry at delivering results on these issues and shows substantially less promise.

Finally, there is the matter of conflicts of interest. The psychiatrists involved in determining which conditions belong in the manual (which is to say, which mental illnesses exist and which do not), and which symptoms correlate with which illnesses, often have financial ties to the pharmaceutical industry. A study published in 2006 on pharmaceutical ties among those who worked on the DSM-IV found some disturbing numbers. From the abstract:

RESULTS:

Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on 'Mood Disorders' and 'Schizophrenia and Other Psychotic Disorders' had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%).

CONCLUSIONS:

Our inquiry into the relationships between DSM panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.

This does not prove that the DSM is essentially a product of the pharmaceutical industry's desire to sell more drugs; it does suggest, however, that the process is probably far from pure and that in in the absence of full transparency regarding the decision-making behind the DSM we should remain skeptical about the results. And that brings us to another valid criticism:  transparency is decidedly lacking. We have no idea how or why the various committees reached the decisions they did; and the fact that those decisions seem to lead toward a larger set of conditions that can be treated with drugs is not encouraging.

All that is criticism enough. And to the extent that the statement from the British psychology community makes those criticisms, I see no problem. But there is a deeper issue here, one summarized by Mary Boyle, emeritus professor at the Univerity of East London:

The statement [by the Division of Clinical Psychology] isn't just an account of the many problems of psychiatric diagnosis and the lack of evidence to support it. It's a call for a completely different way of thinking about mental health problems, away from the idea that they are illnesses with primarily biological causes.

And with this we see that we are dealing with a debate over the nature of mental illness, over its causes and potential treatments. Of course we are also dealing with a turf war, but that may be a topic for a different post.

The psychologists are arguing for social and "psychological" causes for mental illness and want to step away from the psychiatric approach, which seeks somatic approaches. It is probably safe to say that  neither side is entirely right here. But I imagine time will prove the psychiatrists to be more right. The history of medicine is a history of discovering physiological/biological causes for illnesses that were once deemed mysterious or even the result of supernatural intervention.  Since mental phenomena are based in the brain, we need to look to the brain primarily as the source of mental illness. To argue that mental illness does not exist, as some do, or to argue that mental illness is not primarily a function of brain functions, is to argue that the brain, alone among all the organs, always works perfectly and never suffers damage or glitches. Are we to accept that the brain is the only organ in the body that NEVER fails to function as we need and expect it to? Things go wrong often enough with livers and kidneys and gall bladders and hearts and bone marrow; is there any reason at all to think that the brain would be immune to the faults that bedevil the rest of the body?

Psychology has had over a hundred years to find mental causes for mental illnesses or conditions. Psychoanalytical theory, which may have been the most preposterous con of the 20th century, has little to show for itself except several generations of wealthy therapists. Indeed, I imagine that every criticism of the pharmaceutical industry and its products could be leveled against psychoanalysis and its practitioners.

And with this attack on the new DMS, it is likely that the psychologists here are fighting a rear-guard action. If we address only topic of depression, the evidence is adding up that there are indeed biological roots, even if experience also enters into the equation. We have good evidence of genetic predispositions to depression and dysthymia, which is to say that that depression emerges from brain structures and/or chemistry (and is probably rooted in interactions between chemistry and structure; the "brain chemistry" hypothesis that emerged following the limited success of anti-depressants is no longer tenable).

Just in the last few years we have had numerous research breakthroughs addressing the ways that depression has a base in biology. Just one recent study is this one, which found differences in the function of immune system enzymes in depressed patients. Other researchers are looking into how a hodge-podge group of various treatments (SSRIs, exercise, electrical stimulation) can each be effective for depression. Hint: these seem to help with neurogenesis in the hippocampus.

And in recent weeks we have seen yet more evidence that medical interventions can alleviate depression.

For example, we have the latest of several studies showing impressive results from deep brain stimulation,  this one from Germany:

Prof. Dr. Volker Arnd Coenen, neurosurgeon at the Department of Neurosurgery (Klinik und Poliklinik für Neurochirurgie), implanted electrodes into the medial forebrain bundles in the brains of subjects suffering from major depression with the electrodes being connected to a brain pacemaker. The nerve cells were then stimulated by means of a weak electrical current, a method called Deep Brain Stimulation. In a matter of days, in six out of seven patients, symptoms such as anxiety, despondence, listlessness and joylessness had improved considerably.

A good piece here at CNN discusses some of the earlier work in this area, and has some excellent descriptions of depression from one of the test subjects.

Also in the news of late have been studies looking at ketamine, which alleviates depression within 24 hours in some patients, unlike traditional SSRIs, which can take weeks.

And despite the numerous problems with anti-depressants, they do in fact provide relief for many people, despite the deficiencies of the "brain-chemistry" hypothesis.

I don't want to seem to say that psychology is entirely wrong. In this case perhaps some of the more vocal psychologists are overstating the case for their profession. But my first treatment came via the psychologist who put together the Therapeutic Lifestyle Change program.  One of the things I like about the TLC program was that it viewed depression as a somatic (physiological) issue that would respond to physiological treatments, like sunlight and fish oil and exercise. TLC is dedicated to healing brains that have been damaged by deleterious aspects of modern lifestyles: especially poor diets and too much sitting on our asses indoors. The claim that depression is a  "disease of modernity" is a gross oversimplification and is anthropologically unsound (and flies in the face of the ample evidence that depression existed well before modernity). So, the claim that depression is a product of lifestyle is overstated and oversimplified in TLC, but as a summary it is useful enough. Even the anti-rumination element of the program, which seems more purely "psychological" (in that it it trains us to control our thoughts)  relies, to the extent that it is efficacious at all (and I'm not convinced that it is) on the way that replaying thoughts in our minds entrenches associated neural pathways in our brains.

So perhaps psychology is not entirely without promise. But if the discipline is going to insist that mental illness is not biological, or that mental illness does not exist, or that mental illness does not need diagnosis (as one psychologist in that Guardian article claimed) it is going to find itself on the trash heap of failed treatments, somewhere among bleeding, homeopathy, and patent medicine.