In early February, British psychologists and psychiatrists unhappy with proposed changes in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders -- the DSM-5, in its forthcoming incarnation -- staged a successful press conference in London, which generated news coverage around the world.
Meanwhile, the most prominent U.S.-based critic of DSM-5, Allen Frances, MD -- chairman of the task force that developed the fourth DSM edition in 1994 -- has become a regular contributor to the popular Huffington Post website. Last week, he suggested there that the government should force the APA to abandon some of the proposed changes.
And the explosion in social media has allowed other, less well-connected mental health professionals and interested laypeople to create their own platforms for airing concerns about DSM-5 -- starting websites and writing comments on others.
At least in part, the rising furor is driven by the DSM-5 revision schedule. The APA has committed to releasing the final version at its May 2013 meeting. Its internal process for ratifying it requires that it be in essentially final form this winter.
Thus, only a few months remain for critics to sway the DSM-5 leadership.
When Does Grief Become Depression?
Most of the criticism has focused on a few of the many dozens of changes that the DSM-5 working groups have proposed. These include eliminating the so-called bereavement exclusion in diagnosing major depression and adding new diagnoses for people with mild psychotic-like symptoms and problem child behaviors such as severe, repetitive tantrums.
The complaints have a common theme: that the DSM-5 will medicalize -- and therefore stigmatize -- normal human behaviors.
At the London press conference, for example, psychiatrist Nick Craddock, director of the Welsh National Centre for Mental Health in the U.K., argued that removing the bereavement exclusion would have such an effect.
Under DSM-IV criteria, someone who has lost a loved one can be diagnosed with major depression only if depression symptoms last longer than two months or if they include features not typical of normal grief, such as suicidal ideation.
The proposals for DSM-5 would drop this caveat, allowing for diagnosis of major depression two weeks after a loved one's death.
According to the DSM-5 working group on depressive disorders, there is no evidence to justify an exclusion for grief but not for other stressors such as divorce, sudden physical disability, or losing one's home or job.
Defenders of the proposal have also argued that individuals with normal grief may benefit from counseling, which may not be covered by insurance without a DSM-sanctioned diagnosis.
Craddock agreed, but countered that such individuals "did not need a label saying they had a mental illness."
Similar complaints have been leveled at the proposed new diagnosis of attenuated psychosis syndrome. Its proponents intended it to cover people with persistent but mild hallucinatory symptoms and disturbed thinking -- mild enough that the individuals recognize that they aren't real, but serious enough to find the symptoms bothersome.
In a commentary published in the Feb. 18 issue of The Lancet, two researchers said it would be "premature" to include the syndrome in the DSM.
Paolo Fusar-Poli, MD, of King's College London, and Alison R. Yung, PhD, of the University of Melbourne in Australia, said that, from the evidence so far, the population likely to receive the diagnosis "is heterogeneous in presentation, clinical needs, and outcome" -- and thus too ill-defined without more research and additional diagnostic criteria.
'Shrinking the Pool of Normality'
One British psychologist, referring to the DSM-5 as a whole, told the Guardian newspaper that its proposals "are likely to shrink the pool of normality to a puddle."
They also allege that, by expanding the number of people potentially qualifying for a psychiatric diagnosis, DSM-5 will inevitably increase the number treated with drugs.
Another of the speakers at the London press conference, David Pilgrim, of the University of Central Lancashire in Preston, England, called it "hard to avoid the conclusion that DSM-5 will help the interests of the drug companies."
Former New England Journal of Medicine editor Marcia Angell, MD, noted last year in the New York Review of Books that more than half of DSM-5 working group members had "significant industry interests."
Frances, too, has written that the DSM-5 will be a "bonanza for the pharmaceutical industry." But most of his criticisms, which he took public in 2009, have focused on the revision process.
He has been especially concerned with delays in the process -- the APA had originally scheduled publication of DSM-5 for this May, but decided in 2009 to push it back one year -- and what he believes has been a resulting rush to deliver a final product.
He has repeatedly called on the APA to abandon the revision in its current form. Recently he argued that the Obama administration's decision to delay implementation of the ICD-10 classification system in the U.S. undercut the APA's arguments for the May 2013 deadline for DSM-5.
DSM-5 Leaders Stand Their Ground
In a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base.
For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said -- meaning that the APA's annual meeting in May would provide another forum to debate the changes.
"[The proposals] are still open to revision," he said. "The door is still very much open."
Oldham said he was satisfied with the process so far. "It's an enormously long, and difficult, and challenging thing to do," he said. "We're not going to get it perfect. I don't think anybody could. I don't think any previous edition could."
Oldham and Kupfer also argued in favor of removing the bereavement exclusion from the depression criteria.
Said Kupfer, "If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss."
Oldham noted that extreme sadness can be triggered by any number of events -- natural disasters, physical disability, job losses -- yet the DSM-IV created an exclusion only for "bereavement."
He also pointed out that there are "ranges of heritable risk for major depression" -- suggesting that depression may in some sense be normal, yet deserving treatment nonetheless.
The DSM's overarching purpose, Oldham said, is to enable "patients who need treatment [to] get it."
Kupfer conceded that field trials of the revised criteria, by design, were not testing whether the changes would increase or decrease the number of people receiving a particular diagnosis. As a result, the critics' worries won't be refuted or confirmed until after the revisions go into effect.
"We won't get 100% consensus on all the proposals," Oldham said. "That would be totally unrealistic. But I personally think it's been a thorough and careful process. We're going to have disagreement. That's going to happen."