Tuesday, February 9, 2010

DSM-V: Part 2--What's a brain disorder?

Should it be what the DSM says it is?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been coming out since 1952 and has changed dramatically since then. “Human nature has not metamorphosed but each DSM has included more disorders than the last,” writes Frederick Crews in NY Review of Books (Dec.6, 2007). By the fourth edition in 1994, (which some of us were fed on like mothers' milk), there were over 350 disorders listed, “marked by dubious symptoms such as feeling low, worrying, bearing grudges, and smoking.” Those items were put in checklists so that “in Bingo style, for example, a patient who fits five out of the nine listed criteria for depression is tagged with the disorder.”

Christopher Lane, a literary critic and not a psychiatrist, who follows the Freudian line (and hated that the third edition abolished the neuroses), opposes the attempt in these volumes to categorize disorders according to their “detectable traits”. He writes that the DSM has ended “almost a century of psychoanalytic thought and (is) thus a reversion to Victorian psychiatry.” (I think he means in Victorian England these disorders were thought to be morally corrupting and curable, and so they put people away, which led to the way mentally ill people were treated in our country until the 1960s and '70s.)

What is a mental disorder? Well, here's the way the current manual, the DSM-IV-TR, puts it: “While this is a classification of mental disorders, no definition adequately specifies precise boundaries for the concept of a mental disorder. (They) have been defined by a variety of concepts, e.g., distress, dysfunction, dyscontrol, disadvantage, disability, inflexibility, irrationality, syndrome pattern, etiology and statistical deviation. Each is a useful indicator but none is equivalent to the concept and different situations call for different definitions.

“The DSM-IV uses categories to divide mental disorders into types based on criteria sets with defining features,” it continues. “That's the traditional method of organizing. (But) there is no assumption that each category of a mental disorder is a discrete entity with boundaries dividing it from other mental disorders. There is also no assumption that all individuals having the same disorder are alike in all important ways.”

With this much leeway to go on, no wonder the critics are having a field day. As one writer points out, “the rapid pace of pharmaceutical innovation has resulted in a corresponding need for the discovery of new diseases as well. As long as the drug industry continues to develop new products, the American Psychiatric Association guarantees a steady supply of new diseases requiring treatment.” And these find their way into the DSM. There are “diseases and subcategories, co-morbidities, prodromal forms of combined clinical subtypes, shadow syndromes and the like. ..(also) the catch-all category known as Not Otherwise Specified, or NOS, which is applied whenever the symptoms of any given mental disorder do not meet the criteria of any specific disorder within that category.” (bonkersinstitute.org)

Every new disorder is supposed to meet a host of criteria before being accepted into the manual. But transparency is a big issue and “behind the dispute is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders,” writes Lane in the Los Angeles Times. One of the past consultants to the DSM, he says, has revealed that editorial meetings over changes “were often chaotic. There was very little systematic research.” And the main author of the previous volume, Robert Spitzer, said he's against science by committee because of the willy-nilly way that psychiatrists have defined dozens of disorders in the past.

There is suspicion, too, that industry profit motives are bound to influence what goes into the DSM. Lane's book, “Shyness,” exposes efforts of the big drug companies to have shy people view themselves as mentally ill. He cites “the manipulations that promoted social anxiety disorder to a national emergency,” created by Madison Avenue and Big Pharma that have led to billions in profits for the companies. An ad for Zoloft in the American Journal of Psychiatry, August 2003, for instance, shows a woman with downcast eyes and asks: Is she just shy? Or does she have social anxiety disorder?

Sadness is another trait that is focused on. In “The Loss of Sadness,” Allan Horwitz and Jerome Wakefield comment on the fact that depression is now declared epidemic around the world by the World Health Organization. “Those judgments rest on failure to distinguish between major depression, indeed devastating to its sufferers, and lesser episodes of sadness, they argue. “Episodic sadness has always been a socially approved means of adjusting to misfortune and much is lost, both medically and culturally, when it is misread as a depressive disorder.”

The book implies that nearly every non-psychiatric complaint is subject to over-diagnosis unless contextual factors—familial, cultural, relational, financial—are weighed in the balance.” The authors beg the compilers of DSM-V to inquire into each patient's circumstances before concluding that they are faced with a bona fide disorder. But as author Crews points out, the DSM's inability to separate “vague discontents from real maladies” serves the profit making purposes of the medical profession and isn't likely to be changed. (Roy Neville)

From Sad to Mad—the new DSM-V is to be issued in 2012

Part 1--Mystery surrounds picking the diagnoses to be included

The bible of the psychiatric world, the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association, is being rewritten to produce a new version in 2012, a dozen years since the last revision known as the DSM-IV-TR. A draft was issued Feb. 10 to show the world some new diagnoses, like temper dysregulation, and for the first time it calls for binge eating and gambling to be considered disorders.

The fifth revision of this masterful document, which is routinely used by mental health professionals when treating patients and helps insurance companies decide what disorders to cover, serves as well as for clinicians, courts, prisons, drug companies and agencies that regulate drugs. Countries all over the world treat the DSM as gospel, so even minor changes and additions will have powerful ripple effects on mental health diagnoses around the world, notes Christopher Lane writing in the Los Angeles Times (Nov. 16, 2008).

As patients and their families know, a doctor, clinician or other practitioner had better line up treatment that is consistent with one or more of the codes for the individual disorders listed in the diagnostic manual. That's so Medicaid, Medicare or other insurance or NYS-subsidized mental health services, which have their own lists of codes (these may correlate directly to the DSM) can determine which get reimbursed and which do not. These decisions become major issues for community mental health providers in housing, rehabilitation, social and vocational programs, as well as clinics, hospitals and emergency facilities. Some services are declared non-medical or unauthorized for the patient's circumstances and won't be reimbursed.

There are several themes here: (1) how the authors of the new volume deal with the increasing clutter of diagnoses and how they separate them into definable diseases or various non-disease conditions; (2) the secrecy felt to be needed by the authors in researching and analyzing these disorders to avoid bias and lend scientific reliability to the DSM's goals; and (3) whether the ever-expanding numbers of disease categories reflect the pressures of doctors, the medical products industry and drug companies to make bigger profits from the over-diagnosis of these disorders.

In press releases Feb. 10 the draft document is said to leave out obesity as a formal diagnosis, internet addiction or sex addiction, as some have proposed. A bone of contention in the new document is that the checklists of symptoms a patient needs to have to add up to a disorder will be replaced with a scale of severity for every disorder. The experts at the APA say the checklists don't really capture how mental disorders work in the real world.

The DSM is like a cookbook of recipes. For example, in diagnosing major depression, doctors use a checklist of nine symptoms. Patients who meet five out of nine criteria can be said to have major depression. Under the newly proposed system, the severity of the symptoms a patient has would be factored into the diagnosis. The DSM isn't about treatments, unlike the PDR (Physicians Desk Reference) created by the industry for prescription drugs and used as guidelines for treatment.

Discussion of what goes in the manual already has drawn hot reaction from critics and supporters in articles and a book or two over the way the DSM-IV treats the huge array of illnesses and common emotional attitudes like shyness and sadness. Scientists are battling over whether the next revision should be done openly so mental health professionals and the public can follow along, or whether the debate should be held in secret.

As the Lane article puts it, “hanging in the balance is whether, three years from now a set of questionable behaviors with names such as apathy disorder, parental alienation syndrome, premenstrual dysphoric disorder, compulsive buying disorder, internet addiction and relational disorder will be considered full-fledged psychiatric illnesses.” It may sound like an insignificant spat, he remarks, “but the debates have far-reaching consequences. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full scale mental illnesses.” (Roy Neville)

Monday, February 1, 2010

Mentally ill prisoners moving into new residential housing

State Office of Mental Health in a blustery press release says a “first of the nation” residential mental health unit has opened at Marcy Correctional Facility in Oneida County, the result of a 2007 court settlement which forced the state to move mentally ill inmates out of the SHUs (special housing units).
The program, developed by the state Office of Mental Health with the Corrections Department, began taking the first of about 100 inmates in December from various prisons around the state who reside in or are candidates for the notorious special housing (the box, or solitary confinement) and have serious mental illness. The advocacy law firm that won the case against NY state is proud of achieving reform, as are supporters, considering the state has spent almost three years and over $50 million to set it up.

The state was forced to budget $57 million to convert one of its two-story cell blocks at Marcy to the new facility after an out of court settlement in 2007 with Disability Advocates, Inc. of Albany and its law partners. The not for profit law firm, which has won other high-profile lawsuits against the state, claimed that prisoners were put in solitary confinement or lockdown in their own cells because of infractions that were often brought about by their mental illness, not unruly behavior from other causes.

It also charged that disproportionate numbers of mentally ill inmates have been placed in special housing and have spent longer terms there, some for years. This is discriminatory and abusive. Special housing units in NY State prisons consist of locked steel boxes or cages with no amenities where the inmate is locked in for 23 of every 24 hours, given one hour of recreation. The practice, which NYS prisons feature, has brought outcries from families, including those in a prisoners' rights group called MHASC (mental health alternatives to solitary confinement). This group calls the confining boxes torture chambers and has pushed for a SHU bill in the legislature for years to end special housing in prison for the mentally ill altogether. The SHU bill asks the state to review inmates' disciplinary sentences, including those with the most difficult to treat symptoms, in order to remove them from solitary confinement.

Freed from a cell up to four hours a day

According to the state's release, the new facility will replace solitary and offer three or four hours a day for treatment and recreation. When the agreement was announced in April 2007, Cliff Zucker, executive director for Disability Advocates, said “It's going to make a tremendous difference. There are people with serious mental illness who are very, very ill in SHU receiving little treatment and many of those people are discharged directly from those solitary confinement cells to the street.”

MHASC has written that the settlement would make conditions better for mentally ill inmates but improvements were still needed. Keeping people with psychiatric disabilities in isolation units amounts to torture and often exacerbates their illness, they said. They cited cases in which inmates have taken their own lives under those conditions and put the safety of correction officers and others at risk, according to the NY Times (April 23, 2007).

The court agreement came at a time when the legislature, led by Jeff Aubrey in the Assembly and Mike Nozzolio in the Senate, was struggling to pass identical bills that would outlaw putting mentally ill inmates in the special housing. Those bills would set up the residence program and add staff from mental health and corrections to manage these inmates. They also called for more training and an oversight commission to look into abuses of the mentally ill in prison. The bills finally passed, to be implemented in 2011. Then Governor Eliot Spitzer cut back on some provisions and moved to delay its start till 2014. Advocates argued successfully to restore 2011 for startup last summer.

State officials are crowing

Now for the latest release. It says the new facility has opened and “participants will have the opportunity to develop skills that address their individual needs, with at least four hours a day of out of cell treatment and programming, primarily in open group settings. Congregate exercise will be allowed for inmates who have demonstrated treatment progress.” It says earlier steps have included screening on admission for all inmates, a wide array of treatment programs and special attention to aftercare when they're released (per OMH Commissioner Michael Hogan).

But a lawyer at Disability Advocates has some questions in the early going. She said while many prisoners are designated as having serious mental illness, not all have been designated with serious mental illness who should be. The big goal is the quality of the program, she pointed out, and people should be assessed so they have this program if needed. Some of those have BHUs, behavioral health units, for the men where they already get four hours a day out of the cell in the later phases., but the program has not been a success, with few inmates graduating and now it has a very low enrollment. The RMHU (residential mental health unit) will need to be different. Corrections officers will have to be well trained and stay with the program, she added.

The mentally ill shouldn't be in there at all

It's the remorseless tone of the state press release that gets you down. They don't admit to any wrong. They think the world should reward them for what they've done to help. Sure, the settlement is a triumph for the law firm in Albany, the families and the men themselves. But look at this: Here are men who are very sick, who may well have been jailed because of what their mental illness caused, not their being criminals with prior records. They've been pushed around by a hide-bound prison system that rewards order and discipline and punishes slowness to react and follow directions. Some can't adjust to those conditions. If they are stuck in solitary, their illness gets worse in these tiny cells and causes them to become more disruptive than before. That in turn, lengthens their sentence in the SHU.

The court agreed that these men are being abused and maltreated because of their mental illness. But in its first resounding statement to mark the opening of its “new Jerusalem” facility, NY State goes on record as saying the new program “builds on 15 years of enhanced services for inmates with mental illness.” The state fails to accept that tens of thousands of mentally ill prisoners—fathers and sons and husbands, people we know, have been thrust into these awful cells. And they all have to come out of there some day. Instead, the state boasts about how good it will be for some of them, up to 100 at a time, to get three or four hours out of a cell each day instead of one hour.

The press release calls this “the most comprehensive and complex mental health prison treatment program developed in the US in the past 20 years.” One might add that only in New York, with its regressive prison mentality toward the mentally ill do they need such a momentous change of policy. They've spent millions of dollars of taxpayer money on the new prison blocks with their uncompromising rows of steel cells. The prison unions seem to have gotten what they want out of this: more than $50 million in new construction, hiring a considerable number of additional security guards and special training for the guards and their supervisors to manage things in the new residence units. The press release says this would be one-week training, which won't go very far unless the men are well motivated.

What they're doing is still a long way from what is needed. Someone mentally sick and disruptive should get help through the Kendra's Law program and alternative treatment courts before they have to go to jail or prison. They need to hook up with medical treatment and services in the community, and someone should be held responsible to see they stay on medicine. If they can't make it they need to be placed in temporary hospital custody where treatment is at hand, as many times as necessary; not put in the unholy places our prisons have become. (Roy Neville)