DSM-5: A Ruse By Any Other Name...

In psychiatry, "a rose is a rose is a rose" as Gertrude Stein put it. That's according to an editorial in the American Journal of Psychiatry called: The Initial Field Trials of DSM-5: New Blooms and Old Thorns.

Like the authors, I was searching for some petal-based puns to start this piece off, but then I found this "flower with an uncanny resemblance to a MONKEY" which I think does the job quite nicely:

Anyway, the editorial is about the upcoming, controversial fifth revision to the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA).

A great deal has been written about the DSM-5 over the past few years, as "the rough beast, its hour come round at last / Slouches towards Bethlehem to be born" (see, I can reference early-20th-century poetry too).

But now the talk has moved into a new phase, because the results of the DSM-5 'field trials' are finally out. In these studies, the reliability of the new diagnostic criteria for different psychiatric disorders was measured. The new editorial is a summary and discussion of the field trial data.

Two different psychiatrists assessed each patient, and the agreement between their diagnoses was calculated, as the kappa statistic, where 0 indicates no correlation at all and 1 is perfect.

It turns out that the reliabilities of most DSM-5 disorders were not very good. The majority were around 0.5, which is at best mediocre. These included such pillars of psychiatric diagnosis like schizophrenia, bipolar disorder, and alcoholism.

Others were worse. Depression, had a frankly crap kappa of 0.28, and the new 'Mixed Anxiety-Depressive Disorder' came in at -0.004 (sic). It was completely meaningless.

The American Journal editorial was written by a group of senior DSM-5 team members. I'm sure they wanted to write a triumphant presentation of their work, but in fact the tone is subdued, even apologetic in places:

As for most new endeavours, the end results are mixed, with both positive and disappointing findings...Experienced clinicians have severe reservations about the proposed research diagnostic scheme for personality disorder...like its predecessors, DSM-5 does not accomplish all that it intended, but it marks continued progress for many patients for whom the benefits of diagnoses and treatment were previously unrealized.

Remember: this is the journal published by the organization responsible for the DSM and even they don't much like it.

But the real story is even worse. The previous editions of the DSM also conducted field trials. These trials had a system to describe different kappa values: for example, 0.6-0.8 was 'satisfactory'.

However, the new DSM-5 studies used a different, lower threshold. They simply moved the goalposts, deeming lower kappa values to be good. At one point, they wrote that values of above 0.8 would be 'miraculous' and above 0.6 a 'cause for celebration', yet this wasn't the view of previous DSM developers.

The indispensable 1boringoldman blog has a nice graphic showing the results of the DSM-5 trials, with the kappas graded according to the old vs. the new criteria. As you can see, the grass is greener on the new side.

The fact is that the DSM-5 field trial results are worse than the results from DSM-III, the 1980 version that's served mostly unchanged for 30 years (DSM-IV made fairly modest changes.) The reliabilities have got worse - despite the editorial's claims of 'continued progress'. It's true that the DSM-5 field trials were a lot bigger and conducted rather differently, but still, it's a serious warning sign.

Finally, there was great variability in the results between different hospitals - in other words the reliability scores were not, themselves, reliable. Some institutions achieved much higher kappa values than others, but it's anyone's guess how they managed to do so.

Still, there's great news: the DSM-5 is just a piece of paper (well, a big stack of them). Any psychiatrist is free to ignore it - as the creator of the more reliable DSM-IV (not III, oops) is now urging them to do.

Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, and Yager J (2013). The Initial Field Trials of DSM-5: New Blooms and Old Thorns. The American Journal of Psychiatry, 170 (1), 1-5 PMID: 23288382

DSM-V, a Prenatal Health Check

Last month the proposed draft of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) came out.

In my post at the time I was pretty critical of several aspects of the new DSM. Many many other blogs have discussed DSM-V, as have older media. As you'd expect with such a complex and controversial issue as psychiatric diagnosis, opinions have varied widely, but one thing stands out: people are debating this. Everyone's got something to say about it, professionals and laypeople.

Debate is usually thought to be healthy, but I think in this case, it's a very bad sign for DSM-V. The previous editions, like DSM-IV, were presented to the world as a big list of mental disorders carrying the authority of the American Psychiatric Association. That's why people called the DSM the Bible of psychiatry - it was supposedly revealed truth as handed down by a consensus group of experts. If not infallible, it was at least something to take note of. There have always been critics of the DSM, but until recently, they were the underdogs, chipping away at an imposing edifice.

But DSM-V won't be imposing. People are criticizing it before it's been finalized, and even bystanders can see that there's really no consensus on many important issues. The very fact that everyone's discussing the proposed changes to the Manual is also telling: if the DSM is a Bible, why does it need to be revised so often?

My prediction is that when DSM-V does arrive (May 2013 is the current expected birth date) , it will be a non-event. By then the debates will have happened. I suspect that few researchers are going to end up deciding to invest their time, money and reputation in the new disorders added in DSM-V. Why study "temper regulation disorder with dysphoria" (TDDD) when it was controversial before it even officially existed? Despite the shiny new edition, we may be using DSM-IV for all intents and purposes for a long time to come.

DSM-5 R.I.P?

Yesterday, the proposed new DSM-5 revision of the American Psychiatric Associations "Bible of Psychiatry" came under yet more criticism.

Aaron T. Beck, the father of currently-mega-popular cognitive behavioural therapy, started it off with an attack on the upcoming changes to one diagnosis, Generalized Anxiety Disorder; but many of the points also apply to the other DSM-5 proposals:

The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5... many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such "false-positives" will result in an artificial increase in the prevalence of GAD and will have further negative consequences.

Then from across the Atlantic, and also across the psychotherapy-vs-medication divide, came another piece of criticism. The authors are all associated with the European Medicines Agency (EMA, Europe's equivalent of the FDA), or with national drug regulators. Although they're writing in a personal capacity, this is still big news if you ask me.

These authors start out by saying that the EMA is broadly in favour of DSM reform, but they then attack one of the key DSM-5 innovations - the move towards 'dimensional measures' of symptoms in addition to diagnoses:

One of our main concerns is related to potential future [drug] indications based on an effect on a dimension that is independent of diagnostic categories (although we acknowledge that non-specific claims are common in other areas, such as analgesics for pain). As an example, cognitive impairments are common in psychiatric disorders, but they do not have a unique clinical pattern or a unitary cause.

We therefore believe that, at present, such a cross-cutting approach may increase heterogeneity in patient populations and make the assessment of the benefit–risk balance more difficult. Similarly, the use of dimensions as key secondary end points in many different diagnostic categories may lead to pseudospecific indications and polypharmacy. As a general rule, a therapeutic indication should be a well-recognized clinical entity that is clearly distinguishable from other conditions...

They also echo Beck in warning of over-diagnosis and over-medicalization:

Current proposals to reclassify some conditions that were subthreshold or prodromal as distinct syndromes or disorders could have implications for clinical trials. The inclusion of milder or very early cases of psychiatric disorders may lead to an increase in the number of non-disordered (false-positive) patients in clinical trials, and to an increase in the placebo effect, as less severe cases are more likely to respond to placebo. It may therefore be difficult to show a statistically significant difference [of drug over placebo]...

This raises another highly controversial issue: the risk of medicalization of the normal population. In this respect, a strong concern comes from the proposal to remove bereavement exclusion from the criteria for major depressive disorder, implying that all individuals with ‘normal grief’ might be considered as patients in the future.

Regular readers will remember that I've covered both overdiagnosis screwing up clinical trials, and the bereavement debate.

Two and a half years ago, shortly after the first draft of the DSM-5 was made public, I predicted that the eventual release of DSM-5 would be a non-event because, by then, it would have been widely debated and criticized, destroying the illusion of expert consensus that any such document must have in order to succeed.

I think events have borne this out. An awful lot of professionals, patients, and their relatives, will reject the changes in favour of sticking with the DSM-IV or other criteria. Without swift and general acceptance, a document like the DSM is just paper. It seems increasingly likely that the DSM-5 is going to be dead on arrival.

Starcevic V, Portman ME, & Beck AT (2012). Generalized anxiety disorder: between neglect and an epidemic. The Journal of nervous and mental disease, 200 (8), 664-7 PMID: 22850300

Florence Butlen-Ducuing et al (2012). DSM‑5 and clinical trials in psychiatry: challenges to come? Nature Reviews: Drug Discovery DOI: 10.1038/nrd3811

Most People Experience "Mental Illness" By Age 32

Mental illness: how common is it? A popular answer is one in four - 25% of people will experience it at least once in their lives. In fact, most published research suggests that the lifetime rate is higher, around 30-50%, in Western nations.

That's a lot. But even this may be a serious underestimate, according to a new paper, How common are common mental disorders? The study compared the proportion of people reporting mental illness under two different research methods: retrospective and prospective.

Retrospective means asking people to think back and remember whether they ever have felt a certain way. A prospective study, however, recruits people and then follows them up for a certain length of time, asking them how they feel at regular intervals.

The obvious advantage of prospective studies is that there is less chance of forgetting. In a retrospective study, people are required to remember how they were feeling years, or even decades, ago. Human memory just isn't that good. A prospective study requires some remembering, as people are generally asked to report how they've felt over the last year, but this is clearly less problematic.

The prospective study in question here included 1,000 people from Dunedin, New Zealand. The volunteers were followed from birth to age 32, and were interviewed at ages 18, 21, 26 and 32. The results were compared to three large retrospective lifetime studies, two American and one from NZ. (1,2,3).

50% of the Dunedin prospective cohort reported at least one "anxiety disorder", 41% reported "depression", 32% confessed to "alcohol dependence" and 18% to "cannabis dependence". (Those were the only conditions studied.) For some reason, we're not told how much overlap there was, but even assuming there was a lot, well over half of all the cohort will have experienced at least one disorder. If the overlap was low, it could be almost all of them. And remember, this is just up to age 32. And there still may have been some forgetting...

Compared to the retrospective studies, these rates are all about twice as high. What does this mean for psychiatry?

First, it suggests that retrospective studies, which are by far the most common, are flawed. People just tend to forget a lot of "mental illness" when asked to remember across the lifetime. More evidence for this comes from the fact that the ratio of past-year to lifetime reported disorders was 38% in the prospective study compared to about 60% in the retrospective ones.

But there's a more profound implication. A growing number of critics have argued that the very high reported lifetime rates of mental disorders mean that the way most psychiatrists diagnose mental illness is flawed. The "Bible" of modern psychiatric diagnosis is the Diagnostic and Statistical Manual (DSM) of Mental Disorders of the American Psychiatric Association. DSM diagnostic criteria were used in the studies in question here.

These results suggest that DSM diagnoses are even more common than previously believed, which only strengthens the critics' case. According to DSM criteria, at least 40% of people experience "Major Depressive Disorder" by age 32.

In which case, what is it? A fairly usual part of human life. So, calling it a disease and treating it with drugs or therapy seems rather presumptuous. Especially since so many people who "suffer" from it manage to not only get over it, but actually forget it ever happened. (Of course, this shouldn't be taken to mean that real, serious clinical depression doesn't exist.)

The authors conclude - listen carefully -

This article is uninformative (and agnostic) about the validity of diagnoses as defined by DSM-IV ... [rather], objections voiced to surveys’ higher than expected lifetime prevalence of disorder are objections to prevalence that is only half what it could be in reality...

Researchers might begin to ask why so many people experience a DSM-defined disorder at least once during their lifetimes, and what this prevalence means for etiological theory, the construct validity of the DSM approach to defining disorder, service-delivery policy, the economic burden of disease, and public perceptions of the stigma of mental disorder.

That hammering sound you hear is another nail sealing the coffin of DSM's credibility. If many* DSM "disorders" are simply descriptions of normal parts of human life, we need to take a long, hard look at those "disorders", and rethink whether they need to labelled and treated as medical problems.

The newest edition of DSM, DSM-5, is currently in development. This would seem like a great opportunity to do just that. Unfortunately, the development process is rapidly degenerating into farce. If DSM-5 does not address the issues raised here, many people will be tempted to give up on DSM entirely.

* Not all: the great majority of people will never meet criteria for schizophrenia or bipolar disorder, for example.

Moffitt, T., Caspi, A., Taylor, A., Kokaua, J., Milne, B., Polanczyk, G., & Poulton, R. (2009). How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment Psychological Medicine DOI: 10.1017/S0033291709991036

Depressed Or Bereaved? (Part 1)

Part 2 is now out here.

My cat died on Tuesday. She may have been a manipulative psychopath, but she was a likeable one. She was 18.On that note, here's a paper about bereavement.

It's been recognized since forever that clinical depression is similar, in many ways, to the experience of grief. Freud wrote about it in 1917, and it was an ancient idea even then. So psychiatrists have long thought that symptoms, which would indicate depression in someone who wasn't bereaved, can be quite normal and healthy as a response to the loss of a loved one. You can't go around diagnosing depression purely on the basis of the symptoms, out of context.

On the other hand, sometimes grief does become pathological - it triggers depression. So equally, you can't just decide to never diagnose depression in the bereaved. How do you tell the difference between "normal" and "complicated" grief, though? This is where opinions differ.

Jerome Wakefield (of Loss of Sadness fame) and colleagues compared two methods. They looked at the NCS survey of the American population, and took everyone who'd suffered a possible depressive episode following bereavement. There were 156 of these.

They then divided these cases into "complicated" grief (depression) vs "uncomplicated" grief, first using the older DSM-III-R criteria, and then with the current DSM-IV ones. Both have a bereavement exclusion for the depression criteria - don't diagnose depression if it's bereavement - but they also have criteria for complicated grief which is depression, exclusions to the exclusion.

The systems differ in two major ways: the older criteria were ambiguous but at the time, they were generally interpreted to mean that you needed to have two features out of a possible five; prolonged duration was one of the list and anything over 12 months was considered "prolonged". In DSM-IV, however, you only need one criterion, and anything over 2 months is prolonged.

What happened? DSM-IV classified many more cases as complicated than the older criteria - 80% vs 45%. That's no surprise there because the criteria are obviously a lot broader. But which was better? In order to evaluate them, they compared the "complicated" vs "normal" episodes on six hallmarks of clinical depression - melancholic features, seeking medical treatment, etc.

They found that "complicated" cases were more severe under both criteria but the difference was much more clear cut using DSM-III-R.

Wakefield et al are not saying that the DSM-III-R criteria were perfect. However, it was better at identifying the severe cases than the DSM-IV, which is worrying because DSM-IV was meant to be an improvement on the old system.

Hang on though. DSM-V is coming soon. Are they planning to put things back to how they were, or invent an even better system? No. They're planning to, er, get rid of the bereavement criteria altogether and treat bereavement just like non-bereavement. Seriously. In other words they are planning to diagnose depression purely on the basis of the symptoms, out of context.

Which is so crazy that Wakefield has written another paper all about it (he's been busy recently), which I'm going to cover in an upcoming post. So stay tuned.

Wakefield JC, Schmitz MF, & Baer JC (2011). Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity? The Journal of nervous and mental disease, 199 (2), 66-73 PMID: 21278534

Is Depression Undertreated?

Neuroskeptic readers will be familiar with the idea that too many people are being treated for mental illness. But not everyone agrees. Many people argue that common mental illnesses, such as depression, are undertreated. Take, for example, a paper just out in the esteemed Archives of General Psychiatry: Depression Care in the United States: Too Little for Too Few.

The authors looked at the results of three large (total N=15,762) surveys designed to measure the prevalence of mental illness in American adults. I've described how these surveys are conducted before: they took a randomly selected representative sample of Americans, and asked them a standardized series of questions (the CIDI interview) about their mood and emotions, in order to try to diagnose mental illness. The interviewers, while trained, were not clinicians.

What did they find? The rate of people experiencing Major Depressive Disorder (MDD), as defined in DSM-IV, in the past year, was 8.3%. When they examined ethnicity, this ranged from 6.7% in African Americans to 11.8% in Puerto Ricans. The average severity of the depression was roughly the same in all ethnic groups.

Of those with MDD, 51% reported that they'd had treatment in the past year, either antidepressants, psychotherapy, or both. This ranged from 53% for Whites down to just 29% of Caribbean Blacks and 33% of Mexican Americans. Therapy was somewhat more popular than drugs in all ethnic groups, although a lot of people used both. However, few of the treatments were classed as "guideline-concordant", i.e. long enough to do any good, which they defined as

use of an antidepressant for at least 60 days with supervision by a psychiatrist, or other prescribing clinician, for at least 4 visits in the past year. For psychotherapy...having at least 4 visits to a mental health professional in the past year lasting on average for at least 30 minutes each.

Only 21% of depressed people were getting such treatment, even though these strike me as very lenient guidelines, especially in the case of psychotherapy - how much good is 2 hours per year doing to do?

*

So depression's undertreated, especially in minorities. Too little, for too few. But this rests on an assumption: that we should treat Major Depressive Disorder.

That might not seem like an assumption, but assumptions generally don't. It seems like common sense, almost a tautology - it's a disorder, of course we should treat it! Yet it's not so simple. DSM-IV criteria for MDD require you to have 5 or more out of a list of 9 symptoms, including either depressed mood or a loss of interest in activities, lasting at least 2 weeks, and causing significant distress or impairment in social, occupational, or other important areas of functioning.

Fair enough. That's quite useful as a way of ensuring that psychiatrists in different countries are talking about the same thing when they talk about depression. But to think that depression is undertreated because only half of people meeting DSM-IV criteria for Major Depressive Disorder are being treated, is to put absolute faith in DSM-IV as a guide to who to treat. This is not what the DSM was meant to be, and there's no evidence it works for that purpose.

Is it really true that people with 5 symptoms need help, and those with 4 don't? Why not 6, or all 9? Why 2 weeks - why not 3 weeks, or 3 months? It's not as if there are loads of studies showing that treating people who have 5 symptoms for 2 weeks, and not treating people who don't, is the best strategy. I'm not aware of any such research. In particular, there's no evidence that people from the general population who meet these criteria when interviewed, but don't seek treatment, would all benefit from treatment as opposed to being left alone. Certainly some would, but they may be a minority.

This is not to say that any other criteria would be better than DSM-IV as guides to treatment, or that there is anything identifiably wrong with the DSM-IV criteria (although there is evidence that antidepressants are not useful in people with relatively "mild" MDD). The point is that doctors don't strictly apply textbook criteria when diagnosing and treating mental illness; they also use clinical judgement.

I don't know any psychiatrist who would prescribe treatment for someone solely on the basis that they met DSM-IV criteria for MDD. They would also want to know about the severity of the symptoms, whether they're related to any stresses or life events, how far they're "out of character" for that individual, etc. In general, they would deploy their training and experience to try to judge whether this person would benefit from treatment. This is why the DSM-IV carries a cautionary statement that "The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills."

So, it's far from clear that we should be treating everyone who answers interview questions in such a way that they meet DSM-IV criteria for Major Depressive Disorder. That's an assumption.

This isn't to say that everyone who needs depression treatment gets it. Sadly, there are many sufferers who would benefit from help and don't get any, or don't get it as early as they should. We need to do more to help such people. In this respect, depression is undertreated, although it's hard to know the extent of the problem. Yet it's quite possible that depression is also overtreated at the same time.

H/T Thanks to The Neurocritic for drawing my attention to this paper.

Gonzalez, H., Vega, W., Williams, D., Tarraf, W., West, B., & Neighbors, H. (2010). Depression Care in the United States: Too Little for Too Few Archives of General Psychiatry, 67 (1), 37-46 DOI: 10.1001/archgenpsychiatry.2009.168

DSM-V: Change We Can Believe In?

So the draft of DSM-V is out.

If, as everyone says, the Diagnostic and Statistical Manual is the Bible of Psychiatry, I'm not sure why it gets heavily edited once every ten years or so. Perhaps the previous versions are a kind of Old Testament, and only the current one represents the New Revelation from the gods of the mind?

Mind Hacks has an excellent summary of the proposed changes. Bear in mind that the book won't be released until 2013. Some of the headlines:

• Asperger's Syndrome is out - everyone's going to have an "autistic spectrum disorder" now.
  
• Personality Disorders are out - kind of. In their place, there's 5 Personality Disorder Types, each of which you can have to varying degrees, and also 6 Personality Traits, each of which you can have to varying degrees.
• Hypoactive Sexual Desire Disorder - the disease which failed-antidepressant-turned-aphrodisiac flibanserin is supposed to treat - is out, to be replaced by Sexual Interest and Arousal Disorder.
• Binge Eating Disorder, Hypersexuality Disorder, and Gambling Addiction are in. Having Fun is not a disorder yet, but that's on the agenda for DSM-VI.

More important, at least in theory, are the Structural, Cross-Cutting, and General Classification Issues. This is where the grand changes to the whole diagnostic approach happen. But it turns out they're pretty modest. First up, the Axis system, by which most disorders were "Axis I", personality disorders which were "Axis II", and other medical illnesses "Axis III", is to be abolished - everything will be on a single Axis from now on. This will have little, if any, practical effect, but will presumably make it easier on whoever it is that has to draw up the contents page of the book.

Excitingly, "dimensional assessments" have been added... but only in a limited way. Some people have long argued that having categorical diagnoses - "schizophrenia", "bipolar disorder", "major depression" etc. - is a mistake, since it forces psychiatrists to pigeon-hole people, and that we should stop thinking in terms of diagnoses and just focus on symptoms: if someone's depressed, say, then treat them for depression, but don't diagnose them with "major depressive disorder".

DSM-V hasn't gone this far - the categorical diagnoses remain in most cases (the exception is Personality Disorders, see above). However, new dimensional assessments have been proposed, which are intended to complement the diagnoses, and some of them will be "cross-cutting" i.e. not tied to one particular diagnosis. See for example here for a cross-cutting questionnaire designed to assess common anxiety, depression and substance abuse symptoms.

Finally, the concept of "mental disorder" is being redefined. In DSM-V a mental disorder is (drumroll)...

A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

C. Must not be merely an expectable response to common stressors and losses...

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society

The main change here is that now it's all about "psychobiological dysfunction", whereas in DSM-IV, it was about "behavioral, psychological, or biological dysfunction". Hmm. I am not sure what this means, if anything.

But read on, and we find something rather remarkable...

J. When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)

This all sounds very nice and sensible. Diagnoses should be helpful, not harmful, right?

No. Diagnoses should be true. The whole point of the DSM is that it's supposed to be an accurate list of the mental diseases that people can suffer from. The diagnoses are in there because they are, in some sense, real, objectively-existing disorders, or at least because the American Psychiatric Association thinks that they are.

This seemingly-innocuous paragraph seems to be an admission that, in fact, disorders are added or subtracted for reasons which have little to do with whether they really, objectively exist or not. This is what's apparently happened in the case of Temper Dysregulation Disorder with Dysphoria (TDDD), a new childhood disorder.

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder. The LA Times quote a psychiatrist on the DSM-V team:

The diagnosis of bipolar [in children] "is being given, we believe, too frequently," said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.

And the DSM-V website has a lengthy rationale for TDDD, to the same effect.

Now, many people agree that pediatric bipolar is being over-diagnosed. As I've written before, pediatric bipolar was considered to be a vanishingly rare disease until about 10 years ago, it still is pretty much everywhere outside the USA.

So we can all sympathize with the sentiment behind TDDD - but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less "strategic" purposes? When the time comes for DSM-VI, and the fashion for "pediatric bipolar" has receded, will TDDD get deleted as no longer necessary? What will happen to all the "TDDD" kids then?

Can't we just decide to diagnose people less? Apparently, that would be a rather too radical change...

The Network of Mental Illness

A provocative but problematic paper just out offers a new perspective on psychiatric symptoms.

The basic idea is that rather than psychiatric disorders being entities, they are just bundles of symptoms which cause each other:

...symptoms are unlikely to be merely passive psychometric indicators of latent conditions; rather, they indicate properties with autonomous causal relevance. That is, when symptoms arise, they can cause other symptoms on their own. For instance, among the symptoms of MDE we find sleep deprivation and concentration problems, while GAD (generalized anxiety disorder) comprises irritability and fatigue. It is feasible that comorbidity between MDE and GAD arises from causal chains of directly related symptoms; e.g., sleep deprivation (MDE)→fatigue (MDE)→concentration problems (GAD)→irritability (GAD).

The authors seem to have mixed up their labels in the middle there, but you see the drift.

This symptom-based approach stands in contrast to the idea that psychiatric illnesses are underlying things which lead to some symptoms. So it's a challenge to the notion of underlying biological dysfunction (except maybe for specific symptoms) but it's equally incompatible with any theory of underlying psychological causes - there's no room for Freudian unconscious "complexes" here.

So there's something very straightforward and un-mysterious about this model, which will either make it attractive or suspect, depending on whether you think human life is mysterious or not.

What's the evidence? First, the authors do an analysis of the DSM-IV diagnostic manual in terms of symptoms. They take every symptom which is mentioned in at least one diagnosis. They found 439 symptoms in total, over 201 disorders, with many symptoms, such as insomnia, shared between lots of different "disorders".

They then used network analysis to create a kind of graph where the "distance" between the nodes (symptoms) is based on the number of shared diagnoses. They found that while some symptoms are unique to just one disorder, there's a core of highly shared symptoms which form a "giant component"

It's a very clever approach but I wonder what it really tells us. The DSM-IV is not data about mental illness. It's data about what we think about mental illness. Actually, it's not even that: it's data about what a particular set of people, at a particular time, were able to agree upon.

DSM-V is coming soon, and before that we had DSM's I, II and III. What about them? Do they have a different network structure? I'd have thought they would, but we don't know.

We've already seen the kinds of politics that lie behind the decision to include or exclude a diagnosis in the DSM. In the upcoming DSM-V they're seriously proposing to add a new diagnosis ("TDDD"), purely in order to stop people getting another diagnosis (childhood "bipolar").

There is a lot of symptom overlap between TDDD and bipolar disorder. Because one was designed for the purpose of diverting patients from the other. But that doesn't tell us anything about real people with real symptoms. This is an extreme example and to be fair to the authors they do acknowledge some of these problems with the DSM, but still.

The authors then show that the symptomatic closeness between DSM-IV disorders predicts the rates of comorbidity between those disorders, as measured in the American population survey the NCS-R. This is true even of disorders which don't share a common symptom but which are connected indirectly by a mutual friendship, as it were.

Finally they show that a statistical model based on interacting symptoms can predict the prevalence of depression (10% per year according to the NCS-R survey) and GAD (3% per year). It does so much better than a random model in which symptoms randomly interact.

However, I'm not convinced that all these show us that the symptom-network approach is the best model to explain the occurence of these disorders. It only shows us that it's a model that works better than a crazy random model. I'm also not sure that being able to model the NCS-R data is even a good thing, since these data are themselves of questionable validity.

But it's a genuinely interesting approach and well worth following up.

Borsboom D, Cramer AO, Schmittmann VD, Epskamp S, and Waldorp LJ (2011). The small world of psychopathology. PloS one, 6 (11) PMID: 22114671

Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

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The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

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Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

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Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.

Depressed or Bereaved? (Part 2)

In Part 1, I discussed a paper by Jerome Wakefield examining the issue of where to draw the line between normal grief and clinical depression.


The line moved in the American Psychiatric Association's DSM diagnostic system when the previous DSM-III edition was replaced by the current DSM-IV. Specifically, the "bereavement exclusion" was made narrower.

The bereavement exclusion says that you shouldn't diagnose depression in someone whose "depressive" symptoms are a result of grief - unless they're particularly severe or prolonged when you should. DSM-IV lowered the bar for "severe" and "prolonged", thus making grief more likely to be classed as depression. Wakefield argued that the change made things worse.

But DSM-V is on its way soon. The draft was put up online in 2010, and it turns out that depression is to have no bereavement exclusion at all. Grief can be diagnosed as depression in exactly the same way as depressive symptoms which come out of the blue.

The draft itself offered just one sentence by way of justification for this. However, big cheese psychiatrist Kenneth S. Kendler recently posted a brief note defending the decision. Wakefield has just published a rather longer paper in response.

Wakefield starts off with a bit of scholarly kung-fu. Kendler says that the precursors to the modern DSM, the 1972 Feighner and 1975 RDC criteria, didn't have a bereavement clause for depression either. But they did - albeit not in the criteria themselves, but in the accompanying how-to manuals; the criteria themselves weren't meant to be self-contained, unlike the DSM. Ouch! And so on.

Kendler's sole substantive argument against the exclusion is that it is "not logically defensible" to exclude depression induced by bereavement, if we don't have a similar provision for depression following other severe loss or traumatic events, like becoming unemployed or being diagnosed with cancer.

Wakefield responds that, yes, he has long made exactly that point, and that in his view we should take the context into account, rather than just looking at the symptoms, in grief and many other cases. However, as he points out, it is better to do this for one class of events (bereavement), than for none at all. He quotes Emerson's famous warning that "A foolish consistency is the hobgoblin of little minds". It's better to be partly right, than consistently wrong.

Personally, I'm sympathetic to Wakefield's argument that the bereavement exclusion should be extended to cover non-bereavement events, but I'm also concerned that this could lead to underdiagnosis if it relied too much on self-report.

The problem is that depression usually feels like it's been caused by something that's happened, but this doesn't mean it was; one of the most insidious features of depression is that it makes things seem much worse than they actually are, so it seems like the depression is an appropriate reaction to real difficulties, when to anyone else, or to yourself looking back on it after recovery, it was completely out of proportion. So it's a tricky one.

Anyway, back to bereavement; Kendler curiously ends up by agreeing that there ought to be a bereavement clause - in practice. He says that just because someone meets criteria for depression does not mean we have to treat them:

...diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated ... a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation.

If the criteria for major depression are met, then he or she would then have the opportunity to assess whether a conservative watch and wait approach is indicated or whether, because of suicidal ideation, major role impairment or a substantial clinical worsening the benefits of treatment outweigh the limitations.

The final sentence is lifted almost word for word from the current bereavement clause, so this seems to be an admission that the exclusion is, after all, valid, as part of the clinical decision-making process, rather than the diagnostic system.

OK, but as Wakefield points out, why misdiagnose people if you can help it? It seems to be tempting fate. Kendler says that a "good psychiatrist" wouldn't treat normal, uncomplicated bereavement as depression. But what about the bad ones? Why on earth would you deliberately make your system such that good psychiatrists would ignore it?

More importantly, scrapping the bereavement criterion would render the whole concept of Major Depression meaningless. Almost everyone suffers grief at some point in their lives. Already, 40% of people meet criteria for depression by age 32, and that's with a bereavement exclusion.

Scrap it and, I don't know, 80% will meet criteria by that age - so the criteria will be useless as a guide to identifying the people who actually have depression as opposed to the ones who have just suffered grief. We're already not far off that point, but this would really take the biscuit.

Wakefield JC (2011) Should Uncomplicated Bereavement-Related Depression Be Reclassified as a Disorder in the DSM-5? The Journal of nervous and mental disease, 199 (3), 203-8 PMID: 21346493

So Apparantly I'm Bipolar

According to a new paper, yours truly is bipolar.


I've written before of my experience of depression, and the fact that I take antidepressants, but I've never been diagnosed with bipolar.

I've taken a few drugs in my time. On certain dopamine-based drugs I got euphoric, filled with energy, talkative, confident, with no need for sleep, and a boundless desire to do stuff, which is textbook hypomania. So I think I know what it feels like, and I can confidently say that it has never happened to me out of the blue.

On antidepressants, I have had some mild experiences of this type. Ironically, the closest I've come to it was when I quit an SSRI antidepressant. I've also experienced periods of irritability and agitation on antidepressants. Either way, that's antidepressants. Bipolar is when you get high on your own supply of neurotransmitters.

Well, it used to be. Jules Angst et al have got some new, broader criteria for "bipolarity" in depression. They say that manic symptoms in response to antidepressants do count, exactly like out-of-the-blue mania.

What's more, under the new "Bipolar Specifier" criteria, there's no minimum duration. Under existing criteria the symptoms have to last 4 or 7 days, depending on severity. Under the new regime if you've ever been irritable, high, agitated or hyperactive, on antidepressants or not, you meet "Bipolar Specifier" criteria, so long as it was marked enough that someone else noticed it.

All you need is:

an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment.

The bipolar net just got bigger. And they caught me in it. Me and 47% of depressed people in their study. They recruited 509 psychiatrists from around the world, and got each of them to assess between 10 and 20 consecutive adult depressed patients who were referred to them for evaluation or treatment. A total of 5635 patients were included.

Only 16% met existing DSM-IV criteria for bipolar disorder, so the new system with 47% identified an "extra" 31%, trebling the number of bipolar cases.

A cynic would say that this is a breathtaking piece of psychiatric marketing. You give people antidepressants, then you diagnose them with bipolar on the basis of their reaction to those drugs, thus justifying selling them yet more drugs.

The cynic would not be surprised to learn that this study was sponsored by pharmaceutical company Sanofi.

All investigators recruited received fees, on a per patient basis, from sanofi-aventis in recognition of their participation in the study....The sponsor of this study (sanofi-aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.

In fairness, the authors do show that patients meeting their criteria tend to have characteristics typical of bipolar people. And they show that their system is at least as good as DSM-IV at picking out these cases:

For example, DSM-IV bipolar patients had a younger age of onset than DSM-IV depressed ones. "Bipolar specifier" patients did too, compared to the 53% who didn't meet the criteria. Same for a family history of manic symptoms, multiple episodes, and shorter episodes. All of those are pretty well established correlates of bipolar disorder.

That's fine, and the results are better than I expected when I picked up this paper. But all this shows us is that the bipolar specifier was no worse than the DSM-IV criteria as applied in this study.

It doesn't tell us whether either was any good.

DSM-IV criteria were used in a mechanical cookbook fashion - symptoms were assessed by the psychiatrist, written down, sent back to the study authors, who then diagnosed them if they ticked enough boxes. Is that a good approach? We don't know.

Most importantly, we have no idea whether these people would do better being treated as bipolar rather than as depressed. The difference being that bipolar people get mood stabilizers. Maybe these people would benefit from mood stabilizers, maybe not. Existing literature on mood stabilizers in bipolar people can't be assumed to generalize to these 47%.

In the discussion, the authors argue that antidepressants are not much good in bipolar people, whereas mood stabilizers are. Fun fact: Sanofi make many of the most popular formulations of valproic acid/valproate , a big selling mood stabilizer.

I think that is no coincidence. Maybe that sounds crazy, but hey, what do you expect? I'm bipolar.

Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH, & for the BRIDGE Study Group (2011). Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study. Archives of general psychiatry, 68 (8), 791-798 PMID: 21810644

DSM-5: A Little Mix Up

Proposals in the upcoming DSM-5 psychiatric manual for diagnosing "mixed" mood states may be muddled, according to a new paper.

The mixed state - the name alluding to a mix between depression and mania - has traditionally been viewed (more or less) as combining the dysphoria of depression with the energy of mania. Anger, agitation, restlessness and so forth.

I've been depressed and I know only too well the difference between that "active" depression and the "inactive" kind; if I had to choose, I'd always go for the latter, because at least you're in less danger of doing or saying something you later regret.

However, in the proposals for DSM-5, "mixed" episodes as such will be abolished. Instead, a depressive episode will have "mixed features" if it is associated with at least 3 of 7 symptoms normally seen in (hypo)mania. But - and here's the key novelty - those 7 are only the "good" symptoms of mania. Not things like anger, irritability, insomnia or 'aimless' hyperactivity. (Edit: There are also separate criteria for "mixed" manic and hypomanic episodes).

What will this mean? In a new paper, psychiatrists Perlis, Cusin, and Fava tried to find out. The large STAR*D antidepressant trial recruited people with depression, but it gave everyone the Psychiatric Diagnosis Screening Questionnaire (PDSQ), amongst many other measures. This helpfully included six items on "mania symptoms", which correspond pretty closely to the DSM-V proposed "mixed" features.

Perlis et al found that depressed patients who reported experiencing these "mixed" items had a better response to antidepressant treatment. The more mixed symptoms, the more likely they were to get better on the common SSRI citalopram, even adjusting for other variables.

That's the exact opposite of what you'd expect from a measure of "mixed states", as these are thought to be less responsive to antidepressants - maybe even caused by them. There was no placebo group, so it's unclear why they got better, but either way, it's unexpected; the authors declare themselves "surprised". Hmm. What a mystery...

Or maybe not. These manic symptoms are all things that you're not when you're depressed. The 6 items actually make a good summary of what depression, even agitated depression (except maybe #6) isn't.

So, one interpretation of these results is that people who endorsed these items just weren't depressed, at some point in the 6 months prior to doing the PDSQ. Assuming they were depressed at other points that means their mood was variable over time.

People whose depression is variable might well be more likely to recover than the ones whose depression was unrelenting.

Now Perlis et al do consider this -

further models were fit incorporating the IDS-C30 pleasure and reactivity items; results were essentially unchanged indicating that they are unlikely to be confounded by mood variability per se...

But this assumes that the IDS-C30 questionnaire is a good measure of mood variability in this sample. Maybe it's not, and these data are telling us so. I'd have said that's more likely than the idea that these people were actually both cheerful and depressed at the same time, which seems like a contradiction in terms.

Maybe I'm wrong, and these people did feel that, but the problem is, we can't tell, because no-one actually sat down and asked these people what was going on, or heard their account of what they meant by ticking both the "depressed" and "manic" boxes.

Did they experience a strange mixed emotional state in which they simultaneously depressed and happy? Did their mood see-saw from one day to the next? Or weekly, monthly? Were they depressed in the day and happier in the evening? Were they depressed, then back to normal, leading them to see the normal as a 'high', by comparison with the lows? Were they depressed when sober and happy when drunk? Vice versa? Are they experiencing normal ups and downs and interpreting them as 'mood swings' because they've become convinced, for whatever reason, that they have a mood disorder? Did they just have a poor command of English and weren't really trying to say what the highly-educated investigators assume they were?

Who knows? No-one, because no-one asked. Rely on questionnaire 'measures' (as if emotions can be measured) as a replacement for understanding, and you'll end up where this paper does - with a 'result' that's impossible to understand.

Don't seek, and ye shan't find.

It's not great news for the DSM-5 proposals, either way, although defenders could hold out hope that the differences between those criteria and the PDSQ measure might mean the DSM-5 will perform better...

 Perlis, R., Cusin, C., and Fava, M. (2012). Proposed DSM-5 mixed features are associated with greater likelihood of remission in out-patients with major depressive disorder Psychological Medicine, 1-7 DOI: 10.1017/S0033291712000281