We had a diary yesterday that deserves the other side of the story. It cited several newspaper articles and a journal article that linked the authors of the DSM-IV to drug companies. Frightening stuff ... makes you think twice about going to the doctor.
However, since this is not Free Republic or the Tom Cruise Fan Club web site, that diary deserves a clarification.
It needs a clarification because, although both the DSM-IV TR and the pharma-physician relationship are imperfect (the latter much more so), progressives get mental diseases too.
And progressives also deserve to get well.
First, some admissions of my own. I tried to get the journal article in question, but I will have to wait several days for it. Why? The journal is not considered important enough to be one of the hundreds that the NYU Medical Center Library carries. That, in and of itself, is a red flag. However, there could be a reasonable explanation for that, and I will repost another diary when I get the article and read it.
The second admission is that I own 500 dollars of Merck stock and slightly over 1000 dollars of the biotech company Ariad, working on cancer and immune system drugs. I also once had an Ambien pen, which I took from the pharma rep after asking her pointed questions about the neuroscience of the drug. I carried it around on my non-psychiatric rotations and when people asked about it, I warned them off the drug and told them that they should first figure out whether they were eating or drinking too close to bed, had nighttime symptoms of some physical disorder or had thoughts keeping them awake that might require a consult with one of the therapy services. But I had an Ambien pen, until it broke and the news media reported some of the side effects that I had expected based on the drug's thalamocortical interactions.
Oh, yeah ... that's my third admission. I'm a MD/PhD, as of next month ... I have the PhD in neuroscience already and I get the MD next month. I'm going to Psychiatry residency at Massachusetts General Hospital and the McLean Psychiatric Hospital in Belmont, MA in a joint program.
And that's also my first clarification. Doctors are often woefully underinformed on the science of drugs, and they rely on pharma people WAY too much. But, if you get docs at an academic medical center ... they're often well versed in side effects and mechanisms. They argue about that stuff all the time. Yes, there are still too many of them accepting GIFTS. Even I accept free food, although I consider the price of admission at least one pointed scientific question for the pharma rep. But can you really begrudge med students and residents free food? I promise I'll stop accepting free food by the end of my residency, when I'm earning 50-60K a year (before taxes).
I digress. The point is, these docs argue ALL the time about treatments, side effects, and even diagnoses.
And I realize that not everyone can see these docs, because many people live too far from an academic center.
But academic physicians are the ones who write the DSM IV TR. The ones who argue.
And that's what the writing session is. One HUGE argument that is now scheduled for every 5-6 years. We're due soon for the DSM V.
Now, the study that was cited in the article referenced in the diary ... that combined the authors of the DSM IV (1994) and the DSM IV TR (2000). The DSM IV is NOT the most recent manual. The Text Revision (TR) is. Why did she combine those two?
Well, for one, there has been a HUGE movement in academic Psychiatry in the last 10 years to refuse pharma gifts. Not everybody thinks it's a great idea, and you will still see LOTS of chotchkes from pharma companies in even the best of hospitals (although at a public hospital like Bellevue or the VA, what hospital administrator is going to turn down a wall clock?). But that means that far fewer people were taking gifts in 1999 (when the TR was first debated) than in 1993 (when the IV was debated). And fewer still now, when the V is being debated.
Prime example? The abstract for the article states that 100% of the Mood Disorders and Schizophrenia panels (for the IV or IV-TR) had ties to drug companies. When I go to my DSM IV TR (available at your local med school library) I see several Columbia names on there, an institution where the anti-gift movement has almost become religion (I actually had to defend my Ambien pen rationale when I interviewed there this past year). I see Aaron Beck's name on there, of the Beck Depression Scale ... another outspoken opponent of pharma gifts in the last 10 years.
And if you read the DSM IV TR ... it's a diagnostic manual, like it says. How you identify catatonic schizophrenia. How long low mood has to last before it can be called depression, and what has to accompany it. And these guidelines are still hotly debated. And we keep doing research to get decent biological markers to accompany the observational ones. But right now, the DSM IV TR is all we have.
But, there are some things that the DSM IV TR is not ... which the other diary just plain got wrong. It doesn't suggest drugs. It doesn't suggest therapy modalities. It doesn't do anything except give definitions for a limited number of neuropsychiatric disorders that a majority of panelists can agree on.
It even has an addendum of the "plurality" disorders, which couldn't get a large enough consensus definition. They are to be used to do more research, to firm them up or throw them out.
And every decent Psych you talk to will state that the DSM system is a stopgap until we get better biological markers (quantifiable objective behavioral tests, imaging, genetics, biochemical markers). And even though it's designed by MANY MANY Psychiatrists, it can be subjective and flawed. Admittedly, we used to define homosexuality as a disorder (back in the mid 20th century).
But it doesn't suggest treatments. That's debated within institutions. So although pharma still has too many reps crawling the halls of hospitals and doctor's offices ... they don't put text in the DSM IV TR like they put text in Congressional Bills.
The other important fact about the DSM IV TR is that it is not supposed to be used to just give 100 labels to people. You can't pick it up and diagnose your friends with 100 things. Not only does someone's behavior have to fit the definition fairly well, but it has to cause them serious disability at work, at home, or in some other significant aspect of their interpersonal relations. This is the point I have taken most to heart in my training thus far. Psychiatric disease can disorder thoughts, but it is first and foremost a disease of relationships.
Now things weren't always this way. In 1994, with the DSM IV, that wasn't gospel across the country. But in the 21st century, we have a higher threshold for diagnoses. That's why I might say "The President is crazy" in the vernacular, but I have no idea whether he's actually mentally unwell. In fact, I suspect he isn't (I know ... it would be easier if he were) because he manages to perform his job (albeit badly) and get along with his colleagues. I might not find Tom Cruise's beliefs about my profession logical or even wise for others to listen to, but he shares them with a whole host of other people who he bonds with, so that alone doesn't make him crazy or his beliefs delusions. It can't just be an odd idea that defies logic and is resistant to evidence. It also has to unravel interpersonal relationships or be tied to other symptoms that do.
One last point for those that made it this far ... the author counts research grants from pharmaceutical companies as financial gain. In fact, 42% of the financially tied DSM IV or DSM IV TR panel members (which was only 56% of that combined sample of panel members from 1994 and 2000) had their ties explained by getting research grants.
Now, the private grant process is also admittedly flawed. There are craptastic articles out there that get done with that kind of money. Companies sometimes take the data, gag the scientist, and sit on the results.
However, much more good comes out of private grant psych research than you would think. First of all, the government has never adequately funded the testing of drugs, because it IS the damn companies' responsibility to test their own stuff. And, given the choice between Lilly conducting their tests and Bellevue (and 100 other sites) conducting tests on Lilly drugs ... I'd rather that the academic physicians take the drug money and conduct the tests. Because when the tests "get bagged" and nothing is published, I'd like that to be outside the pharma company complex walls. What we need to do is make it illegal for silence to be a condition of the grants when the study doesn't go the company's way. They are entitled not to allow publication, since they own the data ... but that doesn't REALLY mean they own the implications of the data. My larger point is, stripping academic physicians of research grants from pharma is not the same as forbidding drug reps to give huge gifts like travel or even like pens. Ideally, I want the biggest names to be doing both investigational research (government and foundationally sponsored) AND helping to get new and hopefully better drugs out there. And those physicians are not the ultra-wealthy ones (although 100-120K is plenty wealthy) who vote GOP. Those are the Psychs I know who work at the VA and listen to Air America on their lunch breaks.
So why in God's name did several newspapers run with such a crummy article? Well, for one thing, newspapers run with crummy information all the time. We here know that all too well. WMD? Bush's leadership? Need I go on?
And even in my outer circle in the Psych community, I have been told by some higher-ups (including in one interview for residency) that Scientologists have basically declared war on us. One esteemed and very well published researcher had his text for the educated layperson turned down because the publisher (a big European name) got cold feet at the last minute about protests from some of the Scientologist authors in their reliable stable of fictional book generators.
Did that help get one or two articles to press? I have no idea, and probably not. I don't think there are enough fundamentalist Scientologist editors and newspaperpeople to make a significant difference. But maybe. We know that some papers, because they worship the almighty dollar (WSJ) or the Mithraic version of Christ (right-wing fundamentalist publications, Scaife's papers), look the other way with shoddy reporting that favors their view. And in the newspaper business, who has time to vet scientific articles? I mean (snark, snark), that's what scientific journals are for!
That's how we end up with "Eggs are good ... no, they're bad" and "Bran is good ... oh, never mind." Because JOURNALISM reports on scientific publications as if they were pronouncements from SCIENCE ... and not a debate between academics. That's why it takes forever to win a Nobel Prize ... they don't want to give it out until enough subsequent publications support your discovery.
And the DSM IV TR ... although it is used as a diagnostic aid (and just a diagnostic aid) ... is also the product of an ongoing debate. As it should be.
So, yeah, we need to get the gifts out of medicine and give better protection to the recipients of grants so it doesn't compromise their role as healers and sources of public information ... but there's no crisis in the DSM IV TR or in Psychiatry. If you think you need help, talk to your friends and your family and consider going to your doc or finding a therapist of some sort. Please.
When I get the article in my email, I'll post a short (I promise) follow up addendum.