DSM-5 will be published on May 20, 2013. Should Europeans be concerned about the publication of a classificatory system that has no legal currency there—especially since not all of Europe’s different social security systems require a diagnosis as a precondition for the reimbursement of the costs of psychiatric care?
I will try to explain succinctly why Europeans should be—indeed are—concerned about the DSM and its effects.
First, the DSM has lost its bet: there are no hard-and-fast biological markers that would allow establishing a psychiatric diagnosis.
The DSM has contributed to a shift in the thinking and paradigms of global psychiatry. Simply put, classical clinical psychiatry and psychoanalytically-inspired theoretical orientations have been replaced by a psychiatry that sees itself as atheoretical, as objective as possible, as consensus-based, and above all, as scientific.
We’ve seen a lot of hope that science could finally unlock the key to mental illnesses. But this firm belief in the scientific psychiatry of the future, held by DSM advocates, has so far proven unfounded: thirty years after its publication, there’s still no confirmed scientific explanation, genetic or biological, for mental disease. Despite the hundreds of millions of dollars that have been invested in this branch of research, we're still waiting for the “salvation” biological markers were supposed to bring. As the research progresses, the task is turning out to be ever-more complex, while the scientific elucidation of mental illness is pushed further and further into the future.
Even after the United States declared the 1990s “the decade of thebrain,” biological psychiatry has so completely failed in its effort to give psychiatry a rock-solid scientific basis that we must at last ask questions about its methodology and epistemological foundations. At the same time, the pharmaceutical industry has continued to produce new psychotropicdrugs at ever-increasing speed.
Second, does the boom of the pharmaceutical industry correspond to scientific progress?
If psychiatric diagnosis remains completely a matter of clinical practice and the etiology of mental disease has not been clarified, how should we understand the astonishing boom of the pharmaceutical industry, which has continued to introduce new psychotropic drugs into the market with great regularity, even though no reliable biological markers for these different diseases have been found?
We see a skillfully maintained confusion between the constant expansion of the research and true scientific breakthroughs, which are in fact minimal. This approach, specific to psychopharmacological research, allows us to classify the behaviors and emotions affected by these products one by one, and to test for small differences between the products’ effects. It is absolutely true that this method provides us with useful information about neurotransmitters, but its aim and ambition is to develop tools for choosing among psychotropic drugs, to find other, more effective ones, and ultimately to draw a kind of atlas, an exploration of all human behavior—of all human emotions—which will be the target, in turn, of future medications.
This results in an exclusive interest in a psychiatry that deals with observable behavior, with only direct and conscious emotions. And this is precisely what the DSM has to offer, with two consequences: one, a synergy between pharmacological research and the development of theDSM’s nosographic categories. Two, a growing pathologization of emotions and behavior, in reaction to the ever-expanding field of action of psychotropic drugs.
What changed with DSM-III?
There’s no need to speak about potential conflicts of interests or any kind of “Big Pharma” conspiracy; this synergy can be explained simply as a domino effect. With DSM-III and its focus on behavioral symptoms, psychiatry entered a new historical era of pharmaco-induced clinical psychiatry, which follows the rhythm of the “marketization” of products that psychotropic medications represent for the booming pharmaceutical industry.
New medication leads to the creation of new diagnoses, or the modification of existing ones. Consequently, it matters little whether theDSM is clinically binding for European psychiatrists, because in our liberal and globalized world both the spirit of the DSM and the pharmaco-induced model of clinical psychiatry are fast becoming universal. Therefore, to answer the initial question: while scientific progress is only modest and does not reach beyond the limits of laboratory environments, market growth is indeed very strong.
What are the consequences of pharmaco-induced psychiatry andDSM methodology?
Psychiatry has entered the new era of the DSM, yet none of the many evaluations carried out in its name in the U.S. and Europe has shown significant or lasting improvement in the mental health of their citizens. To cite just one of many possible examples, between 2000 and 2009, the consumption of antidepressants in the OECD countries increased by an average of 60%. No study has shown a decline in the prevalence ofdepression. Quite the contrary: the suicide rate in Iceland, a country that consumes the highest amount of antidepressants per capita, has been constant for the past ten years.
As the spearhead of pharmaco-induced psychiatry, the DSM has led to a growing medicalization of emotions, whereby the distinctions between normality, its variations, and its pathologies have all but disappeared.
The DSM has also caused an inflation in psychiatric diagnoses that are both clinically and scientifically questionable and that include “catch-all” categories or chimeras that are the source of artificial epidemics, with the result that psychotropic drugs are increasingly prescribed to children, in turn leading to secondary effects such as obesity, heart disease,addiction or overdose, traffic accidents, loss of inhibition, violent acts, etc.—leaving aside the numerous psychological, family-related and social effects, such as the stigma or exclusion caused by mistakenly labeling a person with a psychiatric diagnosis, in the case of false positives.
Just as serious is the fact that the “one-track thinking” of the DSM has led to diminished interest in the social and psychological context of all mental disease, in favor of its biological and behavioral aspects. This has also contributed to new generations of psychiatrists and psychologists being taught to discredit psychotherapeutic and social reintegration practices, which are nonetheless an absolutely essential part of psychiatry’s everyday practice.
DSM methodology, which is based on visual observation or standardized interviews, using a list of different behavioral symptoms (grouped together as “disorders,” based on a consensus rather than scientific evidence) has played a significant part in the fragmentation of the clinical field, where we see a growing number of specialists or specialized centers, often at the expense of the therapeutic alliance and continuity of care, although the latter are both important prognostic factors in long-term illness.
The DSM’s conception of psychiatric diagnosis as a fixed rather than evolving condition has promoted a confusion between justified prevention and haphazard prediction that may sometimes pose a danger to civil liberties.
Finally, the DSM’s focus on expert systems has been a source of numerous “guidelines” which, supposedly to aid diagnosis, encourage already overworked general practitioners (on average 70% of all tranquilizers and antidepressants in Europe are prescribed by GPs) to react to existential complaints with medication.
This has no obvious benefit to patients who are only slightly or moderately depressed and who could receive other forms of therapeutic response. Some medico-economic studies have questioned the prescribing of the most-commonly used psychotropic drugs because of the large difference, firstly, between their theoretical efficacy, i.e., the degree to which the patient is expected to benefit from a given medical intervention, and their real effectiveness—i.e., the benefit obtained by this intervention under everyday conditions. Secondly, there's the even-greater difference between theoretical efficacy and a drug’s efficiency—that is, the resulting medical benefit with respect to the costs of the intervention, expressed in terms of the human or material means needed and, above all, in terms of risks.
The DSM in the Age of Medico-Economics
Initially created as a statistical tool, the DSM was subsequently adopted by the U.S. health authorities and imposed on all stakeholders in the American healthcare system, so that today the ICD-10 still has no legal force in the United States. Given the significance of the U.S. in the western economy, in the context where medical economics—i.e., the economic rationalization of healthcare costs—is annually gaining increasing ground, the adoption of the DSM also indirectly influenced the drafting of the ICD-10, which is now much-closer to the DSM. This was not the case for ICD-9. In other words, the WHO has aligned itself with theDSM.
The entire doctrine of medical economics in fact relies on a classification of diagnoses to evaluate the cost-effectiveness ratio, the cost-utility ratio, or the cost-benefit ratio of a given therapeutic method. Additionally, this classification must be reliable enough to pass the ”inter-rater reliability” threshold, to serve as a comparison tool for different treatments, or to assess the economic costs of a therapeutic innovation.
Versions -III and -IV of the DSM proved to be successful medico-economic tools, but DSM-IV TR and, even more, the coming DSM-5, are increasingly being seen as leading to exorbitant societal costs. By lowering diagnostic threshold they encourage overdiagnosis, and by creating new diagnostic categories they promote overmedicalization, thus harming not just public health but also public finances, which could be put to better use.
Recently, and for these reasons, the DSM has come under increased scrutiny, including from within the field of medical economics itself, where it had previously been most-often viewed as appropriate. It has simultaneously been losing favor in the field of research, when for example Steven Hyman, former director of the National Institute of Mental Health (NIMH), the U.S. government agency funding research in the area of neuroscience, argued that the DSM is detrimental to research. He called for more funding for studies carried out outside its classificatory system.
For about the last two years, we have also seen a mounting wave of criticism against the DSM from within the U.S. healthcare system, including from protests such as the American Psychological Association’s “open letter,” signed by over twelve thousand people; the criticism and subsequent petition by the British Psychological Society; resignations of experts involved in the drafting of DSM-5, such as the two members of thePersonality Disorders Work Group, but also protests from various actors of the civil society, e.g., the healthcare users, psychiatry survivors, member organizations of Mental Health Europe, the STOP DSMcampaign, which is based in continental Europe and South America, and so on. These initiatives have led to the creation of two collaborating committees: “The Committee to Boycott the DSM-5” and “The International DSM-5 Response Committee.”
Throughout Europe and whenever possible, we must continue to develop alternative systems of classification, transcoding them into ICD-10 to preserve the homogeneity necessary for international exchange, as it is the case in France with the French Classification of Child and Adolescent Mental Disorders (CFTMEA).
These alternative classification systems should be established incollaboration with users of psychiatry to avoid stigmatizing labels, and the place and knowledge of these users must be fully recognized.
Finally, European clinicians who contribute to the drafting of the futureICD-11 must fully take into account the criticisms of the DSM-5 so as not to reproduce its mistakes, and must distance themselves from DSM-5methodology, since it is so flawed. However, a boycott is not an end in itself: we need a constructive approach and cannot simply protest theDSM-5 or advocate a return to the time before DSM-III, or even flatly refuse the improvements brought by biological psychiatry and psychotropic medication on ideological grounds.
Therefore, as a second step, which should be devoted to reflection and discussion, it is essential that all political and group action such as the boycott (this is the ambitious goal set by the two boycott committees) allow for a dialogue between the different currents of European psychiatry, liberated from the yoke of the DSM and its methodology. These currents can be proud to count among themselves critical psychiatry, post-psychiatry, institutional psychotherapy, organo-dynamism, phenomenological psychiatry, sector psychiatry, psychiatry beyond diagnosis, psychiatry of the person, as well as a great variety of therapeutic methods that go beyond the prescription of psychotropic medications and behavioral therapies. These include open dialogue, systemic therapy, psychodrama, the institutional approach,psychoanalysis, interpersonal psychotherapy, narrative therapy, and more, in a spirit of openness to science, of respect for users, for human subjectivity and human rights, and in collaboration with our non-European colleagues who share the same beliefs and concerns.
I will not buy DSM-5. I will not use it. I will not teach it.
Patrick Landman, Université de Paris VII
President of the Initiative for the Clinic of the Subject