In the last installment, we found out that  the APA is trying to thread a camel through the eye of a needle. In their own view, they have to revise the DSM. To do this, they have to address the reification problem–i.e., that many of us, civilians and clinicians alike, have  taken the DSM too seriously and treated the disorders it lists as actual diseases rather than fictive placeholders. To address it, they have to admit that it is a problem, and that they don’t have a solution. They have to fix the plane while it is airborne, but they don’t have the tools or the knowhow to do so, and the more it becomes clear that the plane is in trouble, and the more the mechanics are swearing and banging belowdecks, the more likely it is that the passengers will find out and start asking for a quick landing and a voucher on another airline.

So it is very important to try to keep the passengers in the dark as long as possible. Or, to put it another way, the APA has a product to protect, and the best way to do that, from a corporation’s point of view, is to control the narrative, as the pundits say, about the DSM.

Now, even before the recent events, which I’ll get to in a second, I knew this, because last year I wrote an article about the DSM revision for Wired about the argument between Allen Frances and Michael First, the major players in the DSM-IV revision, and Darrel Regier and David Kupfer, their counterparts on DSM-5. The article was no great shakes, just your usual lunchbucket magazine piece, fair and balanced and bland and forgettable as a soy hot dog with French’s mustard on it. I think Frances came out a little better, but that’s because I think he’s closer to the truth of the matter, and, as one of his colleagues has reminded me about a million times, he’s retired, so he can afford to speak truth to power. And the APA sounded at least reasonable in its willingness to acknowledge that the DSM is more provisional than it is generally made out to be.

Anyway, the forgettable magazine piece is in the process of becoming a book which will probably also be forgettable. And so I went back to my transcripts of conversations with the APA/DSM folks and of course found out all the questions I’d failed to ask and the points I’d failed to get clarified. So I emailed the APA pr apparatchicks and asked them to enlighten me. When exactly did the APA stop taking money from the drug companies for their educational programs, and how exactly was the embargo worded? And did I understand Regier correctly about a highly technical point that I won’t bore you with.

Here’s what I got back for a response.

Dear Gary,

We have received several requests from you for access to APA experts and positions on issues related to the DSM for the book you’re writing. I wanted you to know that we will not be working with you on this project. Last year we gave you free access to several of our officers and DSM experts for the article you wrote for Wired. In spite of the fact that we went to considerable lengths to work with you, the article you produced was deeply negative and biased toward the APA. Because of this track record, we are not interested in working with you further as we have no reason to expect that we would be treated any more fairly in your book than we were in the Wired article.

 Now, why the APA would want to hand me such first-rate evidence of its own paranoia–and spare me having to listen to their talking points, not to mention preemptively decline to have a crack at responding to my book– is beyond me. It’s as incomprehensible as the letter itself, or at least the part where they complain that I was “biased toward” them. But I gather they think that they will make it harder for me to write my book, that maybe if they don’t cooperate I won’t do it. It is in any event evidence of an awfully thin skin, and of a bunker mentality. More disturbingly, it is evidence that they don’t really take their public trust too seriously. Especially when you contrast this to the National institutes of Mental Health, and its director Tom Insel, of whose work I’ve been much more directly critical, and who took the time to read it, and who still bent over backwards to get me an hour of face time that was cordial and fascinating. It’s enough to make you a fan of the government.

So to the recent events. Suzy Chapman is a patient advocate from the UK.  Her website was an excellent compendium of information, archival material, reports, and, yes, criticism of the DSM-5. I have been using it in my research and admiring her tenacity and her fairmindedness. She has opinions but they are way in the background and neither shrill nor strident.

Chapman called her website DSM-5 and ICD Watch: Monitoring the Development of DSM-5, ICD-11 and ICD-10-CM. (The ICD’s are diagnostic systems run by the World Health Organization, and they are also under revision), and her subdomain name was http://dsm5watch.wordpress.com

She also put in a disclaimer, made it clear that she had nothing to do with APA, that she wasn’t dispensing medical, legal, or technical advice. But that didn’t stop the APA from going after her. Not long after they got their DSM-5 trademark approved, and right before Christmas, they sent her this nice holiday card, which she’s kindly allowed me to post here, with her redactions.

Chapman, not in a position to fight, complied almost immediately. Her website is now available at

http://dxrevisionwatch.wordpress.com/
where you can also read about this kerfuffle in more detail.

Why the APA would make themselves into a Goliath is not clear to me. The DSM offers Paranoid Personality Disorder, but this episode makes me wish Frances hadn’t shied away from his proposal for a Self-Defeating Personality Disorder. Because it is not clear to me how they win this one. Not that I really care, at least not about the APA’s fortunes, but are they trying to prove Frances right about his recent, somewhat incendiary, claim that the APA no longer deserves the DSM franchise?

I did ask one of the APA’s trustees about this. He wrote:

You do have to feel a little sorry for the APA. AS John Boehner might say, they’ve been kicking a can down the road for thirty years now. And, not to mix cliches or anything, the chickens are finally coming home to roost.

Way back when, in 1980, the APA published its DSM-III to great acclaim. With its comprehensive listing of hundreds of mental disorders, one for nearly every human foible, the book formalized something that had been going on for years in American society: that we were increasingly turning our troubles over to mental health professionals. Each disorder had a list of criteria that, so the claim went, could be used by clinicians to arrive at diagnoses reliably, meaning that with any given patient, two clinicians were more likely than not to agree on a diagnosis.

This feature of the DSM–its increased reliability–was said by many to have saved American psychiatry, which had taken some serious blows to its credibility in the years leading up to DSM-III. The book reassured the public that psychiatrists knew what they were talking about when they said a person had depression or schizophrenia. It also seemed to guarantee that never again would psychiatry mistake mere deviance from social norms for psychopathology, as it had with homosexuality. Thanks to the DSMs lists, psychiatrists could now claim that, like other doctors, they knew the difference between illness and health, they knew what illnesses they were treating, and they knew those illnesses were real.

The DSM-III was a bestseller, as were its three subsequent revisions. No one really knows why, but really when you’re selling millions of copies of a book, you don’t really stop to ask. You just ring up the cash register.

But at least part of its appeal has to be its claim to be an authoritative compendium of the mental illnesses that exist in nature. This is a useful claim for, say, a lawyer trying to get his client off of a criminal charge on the grounds of mental illness, or for a researcher trying to get grant money to study a mental illness, or for a drug company trying to convince the Food and Drug Administration that its drug is a treatment for a mental illness. Juries, grants administrators, and drug regulators are all assured that the condition is question is a real illness. And so are insurance companies when they fork over the cash for mental health treatments.

But here’s a curious thing. The experts on the DSM, all of them, will tell you, if you ask, that in fact the disorders listed in the book are not real. They will say they are “fictive placeholders.” They will say they are “useful constructs.” They will say they are “our best guess” about what mental illnesses exist in nature. They will tell you that the notion that the disorders are real is a total misapprehension of what the book is really about. And most strikingly, they will tell you that psychiatrists, at least good psychiatrists, are not responsible for that misapprehension. “The DSM is a victim of its own success,” one DSM expert told me. It’s such a good book that people have “taken it too seriously,” and “reified” those constructs.

None of this would necessarily be a problem for the APA if they could continue to have it both ways–to gain authority from the DSM’s appearance even as they can insist that the reality is different. But there are, as Marx might have said, some internal contradictions here. Notably, the DSM doesn’t do such a good job of sorting people into their fictive placeholder categories. People often turn out to have two or three or four mental illnesses, which offends the sensibilities of scientists and laypeople everywhere. As does the fact that epidemiological studies, in which people in a community (as opposed to people who show up at doctors’ offices) are given various screening tests, show that something like 30 percent of us are or will be mntally ill at some point in our lives. And then there are the mental illness epidemics that sweep the land with regularity–childhood bipolar disorder, multiple personality disorder, social anxiety disorder, etc.–and the use of dangerous and sometimes untested drugs to treat these supposed illnesses. Within medicine and in the general public, psychiatry is in danger of once again falling into disrepute. Or, as one of its presidents put it in her farewell address, “Our enemies will use confusion about the DSM to undermine us.”

The DSM is currently under revision. The new DSM will be called the DSM-5. When it was conceived, more than a decade ago, this revision was going to address some of these problems. The obvious–at least to doctors–solution is to tie mental illnesses to their biological causes. You know, find out what’s going on in the brains of suffering people and classify them accordingly. You might think they’ve already done that, what with all the talk of chemical imbalances as the culprit in depression and other disorders, but in fact they haven’t. They haven’t even come close. And they aren’t about to, at least not in time for the DSM-5, which the APA has decided must come out soon.

It’s hard to know just how much that urgency has to do with money, but it’s a safe bet that some of it does. APA revenues are down, largely because drug companies have cut back on their advertising in the APA’s journals. The organization is losing membership. Since January 2010, in fact, it’s dropped by two thousand members, more than five percent. They say they’ve invested $25 million in DSM-5, and clearly they are hoping to reap rewards from it similar to the $104 million and counting that the DSM-IV has brought in–an average of 10 percent of the APA’s revenue over the life of the book. Whatever the proportions, financial need plus challenges to the profession’s credibility add up to an APA with a burning desire to put out a DSM that is different from the previous ones.

Which is the reason I feel sorry for them. A little. Because, as onetime head of the National INstitute of Mental Health and former provost at Harvard and neurobiopsychiatrist Steve Hyman puts it, they have to try to fix the plane while it is in the air. Which means they not only have to keep the thing from crashing and burning, they also have to keep the passengers from freaking out. They have to keep the smiles on the faces of the flight attendants and the calm authority in the voices of the pilots as they try to explain what all that banging and swearing is about. Otherwise, the passengers might ask for parachutes or just demand that they land the damn plane and let them go Greyhound.

It’s like trying to thread a camel through the eye of a needle. Even as it admits that its mental disorders don’t really exist, the APA has to find a way to maintain the public trust. The honest way to do this would be to help people understand what it means to be diagnosed with a “fictive placeholder” rather than a real disease, to talk openly and helpfully about the differences between a depression diagnosis and a diabetes diagnosis, rather than continually trying to insist that they are the same kind of beast. But they would have to count on people’s intelligence to do that, and that is never a safe bet. So instead they bob and weave and prevaricate and do everything they can to control the narrative, as we say these days.

And recently, these efforts took a strange turn, one that shows for once and for all that the APA is a corporation, and like every corporation, will put its interests and those of its stakeholders over the interests of everyone else.

Just when you’re about to give up on your government and join the Tea Party or the Occupiers, it comes along and does something to renew your faith in the institution.

In this case, it’s a study sponsored by the National Institutes of Health and published in the Proceedings of the National Academy of Sciences, right here for free. It’s about what happened when researchers gave Paxil to rats right around the time they got pregnant. What happened to their babies, or pups, as momma rats call them

Turns out the Paxil wasn’t so good for the pups. I recommend you slog through the article, but here’s the 411.

manipulation of 5-HT during early developmentin both in vitro and in vivo models disturbs characteristic chemoarchitectural and electrophysiological brain features, including changes in raphe and callosal connections, sensory processing, and myelin sheath formation. Also, drug-exposed rat pups exhibit neophobia and disrupted juvenile play behavior.

Quick translation: Giving relatively high doses of Paxil to rat mommas early in their pregnancy makes their pups’ brains develop differently. And the pups have stranger anxiety and refrain from play more than the pups of untreated mothers. Male pups sshow these effects more than female.

The researchers argue that these results might be relevant to the increase in autism in human pups, or babies as their mommas call them. Autstic kids also tend to have stranger anxiety and trouble playing with their peers. This is a long, long leap, but it’s also really suggestive, for at least three reasons:

1. It might actually be true that among the factors fueling the autism epidemic is the depression epidemic, or should I say the antidepressant epidemic. The fact that this is even possible should be enough to bring us up short, because what it really means is that this is not something that we know the answer to. Or, to put it another way, in figuring out whether or not to approve these drugs, or to warn women about risks if they are sexually active and uncontracepted, the FDA did not look at acute effects of the SSRIs on these structures and processes. Now, you can’t expect them to look at everything, but really these findings are pretty basic, if you’re interested in what happens in early pregnancies of animals taking antidepressants. Remember, the thalidomide tragedy happened because no one, except one lonely FDA bureaucrat, thought to ask the question about in utero exposure to the drugs. So this one just goes on the long list of variables in the enormous uncontrolled experiment known as the pharmacological era. History will not judge us kindly.

2. Consider what would happen if, say, marijuana or MDMA (Ecstasy) were to turn out to cause these kinds of effects in rats. The National Institute on Drug Abuse, the Drug Czar, the Partnership for a Drug-Free America would already be carpet bombing you with more news about how dangerous these drugs are. Part of the justification for this differential treatment is that antidepressants have clinical value and illicit drugs do not. But at least pot and ecstasy do what they’re supposed to do most of the time, which is more than you can say for Paxil.

3. Psychiatric News ran a story–in the same issue that they ran a piece reporting that psychedelic drugs can change your personality for the better, like that’s news, and another resurrecting the supposedly dead neurotransmitter imbalance theory of depression –on the PNAS report. In it, a psychiatrist worried out loud that the study might “be used as a rationale for pregnant women to not use SSRIs.” As if that would be the worst thing in the world, and just another, you know, hysterical reaction to flames fanned by antipsychiatrists.

This is what psychiatrists always say when their credibility is called into question: that if people stop believing them, they will go off their meds and thus, presumably, off their rockers. But I wonder just how much proof there is about this. I mean, probably one-third of my patients are on psychotropic drugs (other than alcohol or pot, I mean). And most of them have either read my depression book or the articles I’ve written or heard me on the radio or otherwise know I’m a critic of psychiatry and of antideprssants in particular. I talk with them frequently about the topic. It’s a classic setup for someone to try to please me by going off their drugs. And do you know it has never happened? Not once has someone said, “You know, I read that thing of yours, and I’m kicking the habit.” So if it’s not happening to me, I wonder to whom it is happening. I suspect this reaction is more about psychiatrists’ wish to have a good reason to shut up their critics than it is about what actually happens in the real world.

I hate to do this, because it’s old news. But then again, so is Peter Kramer’s argument in yesterday’s Times, in which he argues that the failure of antidepressants to beat placebo in clinical trials is not an indication that the drugs don’t work. Instead he blames it on the research.

Kramer’s problem is that he has to reconcile two apparently contradictory truths: that antidepressants don’t work (according to the FDA data) and that they do (according to his, and many others’, clinical experience, including mine).

The obvious , and scientific, way to deal with this conflict is to say that the evidence that they do work is anecdotal, and that the hard numbers–37 out of 74n trials failed to detect an advantage of drug over placebo, a lousy 2-Hamilton-point aggregate advantage, etc.–tell the real story. That;s the conclusion Kirsch draws and it leads him to say that even when they do work, antidepressants work by placebo effects (amplified by the side effects).

Kramer is right to say that Kirsch’s position is ideologically motivated. he wants to believe that drugs don’t work, so he listens to prozac and hears placebo, which to me simply indicates that he (Kirsch) hasn’t taken enough serotonergic drugs. But Kramer is wrong to say that the dismal results on the trials are an artifact of poor research design, at least in the way he imagines. I suppose the problem could be poor gatekeeping, as Kramer implies, and that the samp0le popuolation in the SSRI trials isn’t sick enough, but this is a pretty lame answer, especially when there’s another one that unties this knot.
It’s true that the Hamilton was standardized on hospitalized patients. it’s also true that it was never meant to be a diagnostic test. it was meant to measure improvement in a population already identified (by Hamilton himself in the old days, by something like the SCID now) with depression who were taking tricyclics (and, probably, MAOIs). The items, more than half of them neurovegetative signs and symptoms, are tailored to the drugs. But when the drugs changed, the tests didn’t. (Note that his is a purely commercial problem–the studies Kirsch looked at were conducted the way they were because they were the way to win the FDA approval game.) And it could be that the Hamilton is a a lousy tool for measuring the effects of SSRIs.

the conclusion that the SSRIs don;t work rests on the assumption that the Hamilton is both the best way to measure depression improvement and the best way to measure the effects of SSRIs; it also assumes that depression is the proper target for the drugs. I think all these assumptions are faulty. Of course, I think the whole idea of depression as a disease is vastly overrated. That’s my prejudice. But I also think the SSRIs do work, i.e., the chemical effect of tweaking serotonin metabolism is in part a change in consciousness. But it’s not one that the Hamilton is sensitive to. That’s why the drugs seem not to work. You can’t find feathers with a magnet.

to me, this outcome is the drug companies hoist on their own petard. They didn’t have to market SSRIs as antidepressants. That was a decision made for commercial reasons as much as scientific or medical and tough luck for them. Not that it matters. They got their indication and they laughed all the way to the bank.

What’s ironic about this is that the person who has done more to prove that antidepressants don’t simply relieve people’s depression is none other than Peter Kramer. But more important is the fact that this kerfuffle is in part due to a willful blindness. There are a few studies of the effects of SSRIs on personality, indicating that wahtever antidepressant effect they have is secondary to the way they change people’s personalities, but in general there’s not much incentive to do those studies. As a society, we’re pretty chary of drugs that change personality. Think about all those ads in which Pharma promises that the drugs won’[t change who you are. That would be a tough sell. It would also turn out that if what you want to do is to transform people’s personalities, there are other serotonergic drugs that do it much better and quicker (LSD, MDMA, etc.) and without daily intake, not to mention old-fashioned psychotherapy which at least doesn’t ruin your sex life.

People sometimes ask me how I got started in the writing racket. Sometimes they’re just curious. Sometimes they’re trying to figure out how to do it themselves. The short answer to the question is that I owe it all to the Unabomber. The long answer is to be found in my first published article, which appeared in McSweeney’s in 1999 and documents my long and fraught relationship with Ted Kaczynski. It turned out to be the lazy man’s way to getting published; after the article ran, all sorts of doors suddenly opened. I’m not recommending this method, but if you want to see how to get a serial killer to run interference for you, or if you’re just curious, you can read all about it right here.