Maybe not. And I’m not just saying that because, having spent way too much of my life in the last couple years thinking and writing about it, the subject has become tiresome. It’s also because the two most important reasons to take the DSM, any DSM, seriously enough to worry about it at all are that it increases treatment, with all the financial and psychochemical burdens that imposes, and that it changes the way people think of their suffering, and therefore of themselves, or, to put it another way, that the DSM plays a role in the formation of identity.
But there is reason to think that both of these are overblown concerns. When it comes to the drug question, the worry is that increased diagnosis will increase the prescription of drugs. And there is no doubt that this has proven to be the case in many instances. For instance, shortly after the introduction of Bipolar Disorder II in the DSM-IV, Abilify, Zyprexa, and the other atypical antipsychotic drugs shot to the top of the sales charts. But does it follow that the diagnosis caused the increase? While it may seem obvious that it did, it’s important to remember that doctors can prescribe any drug for any condition they see fit. That is exactly what happened with the childhood bipolar scandal: an astronomical and catastrophic increase in prescriptions of antipsychotics, with no change to the DSM. Because while a drug company needs a DSM diagnosis to get an indication from the FDA–the right to market the drug for a particular use–there’s nothing to stop a drug company from paying for a study showing that their products can be used to treat a condition not in the DSM and from publicizing that finding. So it’s conceivable that Pharma could have created the right buzz around the atypicals to encourage docs to prescribe them for patients who don’t respond to antidepressants, even without the new diagnostic category. Indeed, much of the increase in use of atypicals is not due to increased bipolar II diagnoses, but rather to the buzz the industry has created about using the atypicals to “boost” the antidepressants in “treatment-resistant depression”-a category you won’t find in the DSM.
Another example: the big worry over the removal of the bereavement exclusion (BE) from the depression diagnosis in the DSM-5 is that it will lead to more prescriptions of antidepressants. In some cases, as in this Atlantic blog, this isn’t a worry, but a virtue of the change: by identifying people whose grief is an expression of an underlying disorder, the removal of the exclusion makes it more likely they will get the appropriate treatment. But as inveterate data miners Ramin Mojtabai and Mark Olfson have pointed out, 72 percent of antidepressant prescriptions are written in the absence of a diagnosis of a mental disorder. Doctors, in other words, are already prescribing drugs regardless of diagnosis. Which to me means that the docs who are already prescribing Prozac to grieving widows and widowers will continue to do so, and those who think they should hold off will also continue to do so. It is possible that some psychiatrists were feeling restrained by the BE, but pharmacological restraint isn’t exactly psychiatrists’ long suit, and even if it was , and now they start handing out the prescriptions more generously, psychiatrists are only writing 20 percent of the prescriptions for antidepressants in the first place. My prediction: removing the BE will lead to a negligible increase in prescriptions, because docs started giving out the drugs to the bereaved a long time ago. And people started wanting to use drugs to change how their lives felt even longer ago.
So what about the identity issue? If I tell a moody woman she has Bipolar Disorder II, or a widower that he has Bereavement-Related Depression, does this make a big difference? Of course, steeped as I am in a Foucaultian tea (or is it Kool-Aid?), and having written an entire tome on the subject, I’m sort of obligated to think so. And indeed I do. But you can’t just present the public with a random list of labels to affix to their troubles and thus to themselves. The list has to be plausible, of course, and it has to have authority–accomplished in the DSM by calling it a medical text–but it also has to resonate with the marketplace. It has to strike a chord. And in a market of people shopping for identities, illness is a hot commodity, especially when it comes to explaining what we don’t like about ourselves, what is troublesome or inconvenient, what makes us anxious about our prospects or those of our children.
Forty years ago, Peter Sedgwick wrote that “the future belongs to illness.” Forty years later, the future has arrived, and the DSM is only one way in which his prophecy has been fulfilled. There are so many benefits to illness–money, sympathy, recognition, an end to wondering about identity–that it is no wonder that a book like the DSM attracts so much notice, and that changes to it are highly contentious. But I believe that we could still be using the DSM-I, with its psychoneurotic disorders like depressive reaction and its transient situational personality disorders like adjustment reaction of later life to label ourselves and each other, to rationalize our drug use, to submit our confusions to experts. IN this respect, the DSM-5 doesn’t really matter, at least not in its specifics. It only matters as a vernacular, as the current language that experts use to tell us who we are.