Tragic stories of misdiagnosis, over-medication, and addiction to prescription medications abound in psychiatry. Though the field asserts that its diagnostic system, described in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), is scientifically founded and clinically accurate, mounting scientific evidence and the clinical experiences of hoards of misdiagnosed and over-medicated patients disagree.
The National Institute of Mental Health (NIMH) announced a few weeks ago that it will be re-orienting its research away from the categories of mental illness described in the DSM. This means that the largest funder of mental health research will no longer be basing its research on the categories in the DSM, such as depression, anxiety, bipolar disorder, and schizophrenia.
This landmark decision could change how researchers everywhere approach the study of mental illness. A center of the National Institute of Health, the NIMH is the largest institution studying mental health and illness in the world, with an annual budget of nearly $1.5 billion dollars.
NIMH's move away from the DSM is a necessary paradigm shift that will, in the long run, enable researchers to find new ways to improve psychiatric diagnosis, and heal a society which is simultaneously under-treated for mental illness and over-medicated in all of the wrong ways.
Dr. Thomas Insel, the director of the NIMH, explained that while the DSM manual has improved reliability and helped to standardize mental health treatment across different health care providers, the diagnostic categories still lack underlying scientific validity. He wrote:
"Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever."
The DSM has long been considered the "bible" for psychiatrists and psychologists, whether they are seeing patients and conducting research. This announcement from the NIMH, just a few weeks before the release of the newest revision of the DSM — a project over a decade in the making — is seen by some as a move to undercut the authority of the DSM and the APA.
Perhaps the disorder in most need of revised scientific diagnostic criteria is attention deficit hyperactivity disorder, or ADHD. ADHD is unscientifically diagnosed, and the drugs used to treat it are commonly abused.
The two most popular drugs for ADHD, Adderall and Vynase, are amphetamine salts that have a very high potential for addiction and abuse. Adderall, Vynase, and other highly addictive stimulant drugs for ADHD are classified by the Drug Enforcement Administration as Schedule II drugs, which is the same category as cocaine. Some studies estimate that as many as 35% of college students try Adderall without a prescription, but there are also many problems of addiction for patients who prescribed legally.
The story of Richard Fee, a college class president and aspiring medical student who became addicted to the ADHD medication Adderall and eventually took his life, was published earlier this year in the New York Times. This story helped to trigger a national conversation about easy and indiscriminate availability of the dangerous medication on college campuses and from unscrupulous medical providers.
Having an official prescription from a doctor gave Richard and his family a false sense of security. The New York Times article noted: “‘The doctor wouldn’t give me anything that’s bad for me,’ Mr. Fee recalled his son saying. ‘I’m not buying it on the street corner.’”
Richard was continually prescribed Adderall even after his parents noticed his addiction and his mental deterioration and subsequently pleaded with his doctors to stop supplying their son. Richard was even able to fool his original doctor to continue supplying Adderall to fuel his addiction after he had been hospitalized for hallucinations and psychosis, a rare but serious side effect of this medication.
The standard answer provided by the psychiatric establishment is that these medications are powerful but extremely safe under the guidance of an experienced clinician. The tragedies described above, are, in their minds, isolated incidents of medical malpractice or unfortunate accidents when the patients were disregarding medical advice or taking their medications not-as-prescribed.
However, a recent study published in Psychological Assessment suggests that the clinicians might not currently have the tools to evaluate the veracity of patients claiming to have ADHD.
In this study, college student subjects who were coached about ADHD from information accessible online were very easily able to come up with the descriptions of symptoms needed to get a diagnosis of ADHD. The subjects’ responses were highly clinically plausible: They did not make the beginner’s mistake of claiming to have every single symptom, and many also mentioned having difficulty concentrating throughout childhood, which is a criterion used by clinicians to distinguish between ADHD and normal distractabililty and procrastination. This finding suggests that clinicians who stick to handing out diagnoses and prescriptions based purely on self-reported symptoms, as they are currently instructed to do by the DSM, are essentially unable to distinguish between real and feigned ADHD and are complicit in the misuse of controlled substances.
Though many college medical clinics have put more strict processes and criteria in place before students claiming to have attention difficulties can receive a diagnosis and prescription, the drug has still been trending on Twitter during college final examination periods.
That same Psychological Assessment article found that cognitive tests, such as the digit memory test, which tests the capacity of a person’s working memory to store strings of numbers, could successfully differentiate between people with ADHD and those attempting to fake ADHD. However, these tests have not been recommended or required by the APA as a part of disgnosis. This comes back to the heart of the NIMH’s decision: In comparison to biological and cognitive tests, symptom-based diagnosis is simply far too inaccurate and easily abused.
The need for more scientifically proven tests for mental illness is central to the NIMH’s decision. The NIMH believes that moving towards biomarkers and specific cognitive performance tests is the future of mental health treatment. Dr. Insel, the director of the NIMH, explained that "studies of biomarkers for ‘depression’ might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms."
To unpack what this means, it is necessary to translate some of these terms for a general audience. Anhedonia is defined as the loss of the ability to experience pleasure from pleasant activities. Anhedonia is a component of multiple mental disorders as defined by the DSM, such as depression, dysthymia, and schizophrenia. Psychomotor retardation, or the slowing of thoughts and physical motions, is often a symptom of severe depression, the depressive episodes of bipolar disorder, and a side-effect of psychiatric drugs for anxiety.
Just defining and explaining these two symptoms that multiple and diverse manifestations across the accepted diagnostic categories demonstrates how futile it would be to base future research around the DSM. Many patients with depression do not exhibit psychomotor retardation, and many patients with psychomotor retardation have a mental disorder other than depression. In order to find the cognitive and biological correlates of this symptom, and in order to identify scientifically valid tests for the correlates, researchers will have to be able to think beyond the DSM. There is simply far too much variation within a disorder like depression to think that it accurately represents a single cognitive or neurobiological state. Attempts to test treatments for this condition is like throwing darts at a scrambled-up dartboard; excellent throws are likely to miss because the target has not been accurately defined.
ADHD is not the only mental disorder in which there is widespread over-diagnosis and doctor-approved misuse of medication. In the 1990s, the prescription drug-of-choice was the new class of antidepressants, selective serotonin reuptake inhibitors (SSRIs) such as Prozac. Memoirs such as Prozac Nation and Listening to Prozac highlighted the potentially transformational effects of this new class of medications, that might even hold promise in helping people become better than normal: happier, more resilient, and more optimistic and anyone might naturally be.
These predictions did not bear fruit, particularly because the new class of antidepressants turned out to be much less effective than earlier thought, particularly for people who are functioning successfully. Acclaimed physician-author Siddartha Mukerjee recently wrote in the New York Times: "Fast forward to 2012 and the same antidepressants that inspired such enthusiasm have become the new villains of modern psycho-pharmacology — over-hyped, over-prescribed chemicals, symptomatic of a pill-happy culture searching for quick fixes for complex mental problems."
A recent study from the Johns Hopkins School of Public Health reveals that fewer than 40% of patients diagnosed with depression by their clinicians actually met the DSM-IV measure of depression. This follows a 2010 finding published in the Journal of the American Medical Association finding that antidepressants have little or no benefits for patients with mild or moderate depression. This study was a meta-analysis, a study that combines re-analyzes all of the published and otherwise available data for the question at hand to have the maximum statistical power and certainty.
Despite this evidence, antidepressants are prescribed to tens of millions of Americans every year, in many cases, indiscriminately and without proper follow-up or complimentary talk therapy. Moreover, the underlying science behind SSRIs has changed drastically. Though the drug commercials told audiences for years that depression was caused by low-levels of serotonin (a mood-related neurotransmitter) in the brain, this has now been completely discredited.
But it is not just certain controversial pharmaceutical treatments that are the subject of exaggerated scientific certainty. This exaggerated certainty extends to overall claims about the medical and scientific rigor of the Diagnostic and Statistical Manual itself.
The idea of the DSM as a guide to evidence-based psychiatric treatment is misleading, as it often reflects the consensus of experts rather than scientifically proved principles. Psychiatrist Simon Sobo, M.D., wrote: “DSM IV too often is used to create an illusion of understanding, for example, obedience to protocols deemed proper treatment by a polling of ‘experts’, but not based on scientific discovery. Equally questionable is the use of DSM IV to dictate ‘evidence based’ treatment, which implies unwarranted scientific validity.”
Though the details of the DSM have been hotly debated by researchers, these debates are often definitional rather than scientific in nature. For example, one of the main focuses of PTSD research over the past few decades was an incredible, lengthy, and largely unproductive debate on just how traumatic an event has to be in order to cause PTSD. While the DSM gets minor revisions over the years, the whole approach of the DSM assigning different mental disorders to patients almost entirely based on the patient’s self-reported clusters of symptoms has never been seriously and substantially rethought.
This is not to say that the DSM is not useful; indeed, it is the most coherent and comprehensive system of diagnosing mental illness currently available. However, the gradual accumulation of minor revisions to the DSM will not create a path to the future of scientific psychiatry, and continuing to overemphasize these blurry diagnostic categories created by the DSM will hold research in this field back.
The APA responded to the NIMH’s decision in a statement by David Kupfer, M.D., the chair of the DSM-V task force. Dr. Kupfer wrote:
"In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant."
Dr. Kupfer also noted that the NIMH's new research criteria "cannot serve us in the here and now, and they cannot supplant DSM-V."
However, the APA's response is both ignorant and unnecessarily defensive. Researchers haven't been able to find biomarkers for "depression" because what we call depression is a complex social and cultural phenomenon that obviously cannot correspond to one singular cognitive or biological cause. What has been previously described as one disorder is probably in fact many.
Unfortunately, the APA is not ready for the paradigm shift which the NIMH has already begun, a shift that will eventually ease and enable the integration of psychiatry and modern neuroscience, and hopefully provide clinicians with better diagnostic tools to prevent dangerous over-medication.