"Patients with mental disorders deserve better."
May 4, 2013 12:46 PM   Subscribe

National Institute of Mental Health director Thomas Insell reports that NIMH will phase out its reliance on the Diagnostic and Statistical Manual of Mental Disorders (DSM), in favor of a revamped psychiatric diagnostic system based on "genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."

This announcement arrives only weeks before the debut of the DSM-V, whose long, tortuous development period was discussed previously.

Responses from bloggers Vaughn Bell at Mindhacks, and John Horgan of Scientific American at Cross-Check.
posted by overeducated_alligator (105 comments total) 34 users marked this as a favorite

 
This is such a sucker punch coming two weeks before DSM-5. I fucking love it.

Modern psychiatry is grade-A make-believe phrenology/four humors-quality garbage, and thank god someone with authority is finally driving nails in the coffin.
posted by crayz at 1:00 PM on May 4, 2013 [9 favorites]


Wow. That is wild. So they are moving to a system that recognizes symptoms (eg as a way of deciding who to include in your clinical trial) but rejects the DSM's way of clustering/taxonomy of those systems into conditions?
posted by LobsterMitten at 1:06 PM on May 4, 2013 [2 favorites]


Oh wow. This is big news!

I'm very curious to see what their new diagnostic criteria will look like. I worry that we're just too ignorant to develop criteria that have much validity, and whatever they come up with will be just as objectionable but cloaked under a dubious veneer of scientific rigor (which is how the DSM-III first got its legs).

Happily, they do say it's meant as a research tool alone not a clinical tool, so that alone will mean that there will be less resistance to changing it in the face of updated evidence. I still wonder how it's going to be put into research practice. Suppose that, tomorrow, a NIMH researcher wants to separate a population into those with schizophrenia and those without. How are they going to do this? Will they use ICD criteria in the meantime, or will they only separate populations based on publicly observable symptoms, or what?
posted by painquale at 1:13 PM on May 4, 2013


The Horgan piece speculates this may be a move to capture some of the benefits of Obama's neuroscience-funding Brain Initiative?
posted by LobsterMitten at 1:14 PM on May 4, 2013 [1 favorite]


This is such a sucker punch coming two weeks before DSM-5. I fucking love it.

Modern psychiatry is grade-A make-believe phrenology/four humors-quality garbage, and thank god someone with authority is finally driving nails in the coffin.


Did you even read it? There's no sucker punch here. The DSM is a reflection of how fucking hard it has been to pin down what exactly causes mental illness, how it manifests besides symptoms and what exactly can be used to treat it precisely.

It seems only natural that the NIMH should be using its precious dollars to look for concrete signifiers of mental illness to more accurately diagnose conditions. Especially now that we have a good feel on how the cognitive side of things are going and we have decent scientific consensus.

I wish luck to the researchers who are going to have to wade through the same clusterfuck that cancer researchers have been wading through for the past half a century.

I'm very curious to see what their new diagnostic criteria will look like. I worry that we're just too ignorant to develop criteria that have much validity, and whatever they come up with will be just as objectionable but cloaked under a dubious veneer of scientific rigor (which is how the DSM-III first got its legs).

It will be based on empirical things you can actually test for. But nobody right now has a fucking clue on the empirical things you can test for, just how these diseases typically manifest themselves as symptoms. The initiative now is to start pinning down how to identify, measure and correct the actual abnormalities in the brain that make up mental illness.

Once we get through a lot of the fuckton of research left to do instead of the current "you have had mania and depression? Well you're bipolar now, let's start throwing medication spaghetti at the wall and see what sticks" we'll have "you have biomarkers J, K and I along with excess levels of hormone X, Y and Z and the CT scan shows part A of the brain to be enlarged and the B part of the brain to be smaller so therefore we can conclude you have mental disease Q that should be efficiently treated by drugs E, F and G".
posted by Talez at 1:20 PM on May 4, 2013 [34 favorites]


It's difficult to deny that the DSM has proved itself to be a thoroughgoing botch of a system, and not a lot about the process of developing the DSM-5 inspires confidence that it's going to be any kind of an improvement. What exactly, though, is the NIMH planning to use for diagnosis coding in the meantime? This whole "Research Domain Criteria Matrix" is still in draft and seems like it will be hellaciously complicated to implement, and if they roll over to using the ICD in the meantime, that's just the DSM all over gain.

Good for them for realizing that mental health nosology needs to be rethought from the ground up; I just hope the gamble pays off. We may not yet have the level of basic research we need to do it well. It would be a shame to lock into path dependency for a system now if we're really thirty years away from being able to design a new one well.
posted by strangely stunted trees at 1:21 PM on May 4, 2013 [1 favorite]


The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.

And such small portions!
posted by scratch at 1:26 PM on May 4, 2013 [6 favorites]


Oh those rats of NIMH!
posted by srboisvert at 1:29 PM on May 4, 2013 [9 favorites]


So how is mental health diagnosis done in other countries? Are there any comparative quality indicators?
posted by Foci for Analysis at 1:30 PM on May 4, 2013


Oh man. I really hope the insurance companies don't use this as a way of weaseling out of covering mental health care.
posted by elizardbits at 1:30 PM on May 4, 2013 [36 favorites]


This is super interesting to someone who's looked at the philosophical stuff surrounding reductionism in philosophy of mind. This is NIMH literally saying, mental disorders are (not "are correlated with" or "result from" but plain "are") biological disorders and we're going to treat them that way.
posted by LobsterMitten at 1:31 PM on May 4, 2013 [9 favorites]


What am I even fucking thinking. Of course they'll manage somehow.
posted by elizardbits at 1:31 PM on May 4, 2013 [14 favorites]


So how is mental health diagnosis done in other countries?

I think they used a different manual called the ICD that's published by the World Health Organization, but it sounds like it has many of the same problems as the DSM.
posted by cosmic.osmo at 1:35 PM on May 4, 2013 [2 favorites]


What am I even fucking thinking. Of course they'll manage somehow.
posted by elizardbits at 3:31 PM on May 4 [+] [!]


Mine already does. Jerks.
posted by fiercecupcake at 1:37 PM on May 4, 2013 [1 favorite]


I think they used a different manual called the ICD that's published by the World Health Organization, but it sounds like it has many of the same problems as the DSM.

No matter where you go mental illness diagnosis is all still based on symptom clusters. We just don't have the knowledge yet. Forget trying to solve the puzzle, we're still trying to figure out what the hell the finished image on the box looks like.

Meawhile mental health professionals in the field only know that the disease looks kind of like a sky and throw all the blue puzzle pieces at the wall hoping that some may lock in together properly or at least in a plausible manner.
posted by Talez at 1:39 PM on May 4, 2013 [2 favorites]


This is super interesting to someone who's looked at the philosophical stuff surrounding reductionism in philosophy of mind. This is NIMH literally saying, mental disorders are (not "are correlated with" or "result from" but plain "are") biological disorders and we're going to treat them that way.

Oh gosh. I didn't notice that they said that. That's terrible. That's like a tech support company deciding to diagnosis all computer problems as hardware problems rather than software bugs because all software originates in hardware.

Maybe they just mean it loosely.
posted by painquale at 1:46 PM on May 4, 2013 [5 favorites]


Mental disorders are biological disorders

That's a bit of a reach. I can understand the frustration with not including biomarkers in diagnosis. But ignoring symptoms is throwing out the baby with the bath water. We don't understand mental illness well enough yet to be making statements like these.
posted by 3.2.3 at 1:50 PM on May 4, 2013 [1 favorite]


crayz: "Modern psychiatry is grade-A make-believe phrenology/four humors-quality garbage"

Absolutely eponysterical.
posted by meehawl at 1:54 PM on May 4, 2013


what is a mental process that is not fundamentally a biological process at it's basis?
posted by edgeways at 1:55 PM on May 4, 2013 [4 favorites]


The DSM has been getting stranger and stranger with each successive release. It's hardly surprising that something like this should eventually happen.
posted by Chocolate Pickle at 1:56 PM on May 4, 2013


Oh man. I really hope the insurance companies don't use this as a way of weaseling out of covering mental health care.

They don't need this to do that. My insurance has recently changed a mental health visit into two separate charges...the office visit ($40 co-pay) and the actual therapy ($100+ out-of-pocket and applied to deductible). It's effectively priced regular counseling visits out of our reach.
posted by Thorzdad at 1:59 PM on May 4, 2013


3.2.3, it doesn't sound like they're ignoring symptoms... it sounds to me like the new plan is to use the existing symptom-taxonomy but not the existing condition-taxonomy (ie, the groupings of symptoms into conditions). So they'll be looking for eg quantifiable measures that correlate with anhedonia (symptom), not depression (condition).

It's possible I'm misunderstanding, though.
posted by LobsterMitten at 2:07 PM on May 4, 2013


edgeways: "what is a mental process that is not fundamentally a biological process at it's basis?"

When it is a social and subjective response to maladaptive treatment behaviors and labelling. Endless studies have tracked people populations tagged with "schizophrenia" or "bipolar" Their development and outcome, frequency and severity of loss of function are dramatically affected by ethic group, social status, drug use, family dynamics and economic, political and demographic/migratory transfers. The biology provides a substrate, but it does not always absolutely determine outcome.
posted by meehawl at 2:09 PM on May 4, 2013 [8 favorites]


When I first saw this on a fellow mefites LJ, I replied the following. Looking at the comments here, it seems I overlooked some of the point of this... I am still skeptical, because I am of the belief that we have a complex of various systems that can't be pinned down to just this or that fucking genetic expression or this specific scan... But I am not denying the value of looking for commonalities and understanding some of the potentially root biological causes.

So here's what I wrote while still in a partially awake haze:

-------------------

Here I thought the DSMV issue was going to be about the conservative twit who was doinga lot of damage to how the DSM was being rewritten.

I disagree with this dumbshits stance. I don't think there are necessarily known genetic factors for various maladies. What do you do about those? MRI scans, perhaps, but what if we don't know what we're looking for. My belief is that many mental issues are emergent phenomena which are not necessarily directly correlated to a genetic factor, or even brain structure.

If a patient is experiencing symptoms, and we have evidence based therapies that work in treating those symptoms and help the patient adjust to our maladjusted society. CBT, for example, is one well known method for treating anxiety disorders, and has been proven in many studies over the years. Why should more expensive tests be done to force a patient to "prove" they have a disorder when simple diagnostic criteria can help evaluate their general needs. It's a waste of money and resources and will drive up the cost of health care even more. DBT, I have heard, is the one treatment that works for people with Borderline Personality Disorder. It has proven efficacy as well. The science belongs in the issue of not mere diagnosis, but in treatment.

I see this more as the sort of "blame the patient" and "mental disorders aren't *real* if they don't have a physical element" (same with psychogenic illnesses)... It's a misuse of the understanding of the scientific method in order to perpetuate certain preconceived notions on how patients are really ill or not. And it will prevent a lot of people who DO need help from getting it, just on the say so of a scan that doesn't necessarily have all the proven knowledge to pinpoint the origins of given disorders as it is.

I'm not a huge fan of some forms of psychiatry, and I would like to see us less medicated if possible, but I'm also a realist when it comes to the need for treatments and for empathy for patients. The doctor seems to be the kind who has none and will only exacerbate the suffering of those who need help the most, the same way we punish and put people through multiple tests to prove they are disabled before they can get any help, in the meantime depleting their family resources and harming the resiliency of the local community in order to save a few bucks due to fears of "cheaters". This guy strikes me as one of those kinds of assholes.
posted by symbioid at 2:29 PM on May 4, 2013 [6 favorites]


I don't think NIMH is ignoring symptoms, they're just not assuming disorders should be principally taxonomized by the clusters of symptoms invoked in the DSM-V taxonomies. The focus is instead on classifications in terms of the underlying cognitive structures that give rise to symptoms.

I'm interpreting this as essentially taking the advice of a 2005 book by Dominic Murphy, Psychiatry in the Scientific Image, in which he argued that:

... the current literature on mental illness--exemplified by the Diagnostic and Statistical Manual of Mental Disorders--is an impediment to research; it lacks a coherent concept of the mental and a satisfactory account of disorder ... the explanation of mental illness should meet the standards of good explanatory practice in the cognitive neurosciences, and ... the classification of mental disorders should group symptoms into conditions based on the causal structure of the normal mind.
posted by airing nerdy laundry at 2:30 PM on May 4, 2013 [1 favorite]


But.. could you not say almost exactly te same thing for what are more commonly termed physical disabilities? "Ethic group, social status, drug use, family dynamics and economic, political and demographic/migratory transfers" sound like variables in a person's life that affects all manner of things, including any random outcome. I don't think anyone would argue that a person's social situation has no bearing on a given disability, but I'm not sure that answer refutes or shows a fundamental difference between what we term (imo erroneously drawing a separate line between) mental illness and physical illness.
posted by edgeways at 2:30 PM on May 4, 2013 [5 favorites]


My point is that there are symptoms that are... shall we say... psychosomatic in origin, or that we may not know what the root causes ARE... To deny those patients who suffer from symptoms relief because "hey, you're not *really* sick" does a disservice to those who need treatment if possible. It infuriates me because I see this with things like a lot of the syndromes, patients are taken seriously,because there's no easy to discern physical origin, and yet the complaints are common and real and... yes... clustered in such a way that there isa clear phenomenon. The mentality behind this is seeing psychology is a purely biological without any sort of attempt at looking at the sociological factors, it's an extreme overreaction, I think instead of trying to find balance between the various components of mental illness. As I said, I can see a benefit for looking into physical causes, but it should not be the only determinant. It strikes me as very hubristic, and a bit like AI researchers, frankly. There's a lot of assumption that we know so much when I think we've barely scratched the surface.

Are they saying we should start to move towards this direction and invest some of our resources in it, or that we should 100% right now say 'fuck the dsm' and ignore anything that isn't grounded in physiological scans? (or in some sense,on preview, some of the issues that edgeways is bringing up, though I'm not sure what point they're making, exactly).
posted by symbioid at 2:37 PM on May 4, 2013 [1 favorite]


Nobody in their right mind has said that people aren't really sick because there's no empirical evidence, only symptoms and nobody's saying 100% fuck the DSM right now.

People need better than 10 years to go from the first symptoms of bipolar and finding the right treatment. The only way we're going to be able to do that is to find the empirical pieces of evidence that can definitively diagnose mental illness and give people the right treatment quickly.
posted by Talez at 2:44 PM on May 4, 2013 [1 favorite]


100% fuck the DSM right now
posted by thelonius at 2:49 PM on May 4, 2013 [1 favorite]


what is a mental process that is not fundamentally a biological process at it's basis?

It depends what you mean by "at its basis". I really think the hardware/software distinction is useful here. All software processes have hardware processes "at their basis" in some respect. However, if your computer is glitchy, you might not find anything wrong at the hardware level. It's true that your fan could be broken and cause the computer to overheat, or maybe someone got peanut butter all over the sound card. But you also might just have a virus, and that'll be invisible to the hardware engineer.

Some (most?) mental disorders are probably going to end up being software glitches of the mind. They could be treatable and curable in the same way that computer viruses are, but by focusing on the hardware, you leave them untreated.
posted by painquale at 3:30 PM on May 4, 2013 [8 favorites]


Insel is in general quite an impressive person, but I went looking for a particular thing in his background and I found it:
Building on the genomics revolution, he created large repositories of DNA and funded many of the first large genotyping and sequencing efforts to identify risk genes. He established autism as a major area of focus for NIMH and led a large increase of NIH funding for autism research. Under his leadership, autism, as a developmental brain disorder, became a prototype for mental disorders, most of which also emerge during development. And during his tenure, NIMH became a leader in global mental health, working closely with the World Health Organization and the Global Alliance for Chronic Disease.
...
The Autism Action Network has called for Insel's resignation,[7] due to alleged conflict of interest (his brother works in the vaccine industry) and outrage at his expressed refusal to unqeuivocally acknowledge the growing number of autism spectrum diagnoses.
Rising rates of Autism have put tremendous pressure on the NIMH and Insel personally (not to mention the vaccine industry), and I'm very much afraid the core purpose of this initiative is to allow Insel to deal with his problem-- but not the problems of people with autism and their families-- by redefining the very category of autism so that it applies to many fewer cases, or perhaps even by eliminating it altogether as we now know it in favor of breaking it down into constituent symptoms, but resisting putting those together into a syndrome, just as LobsterMitten suggests:
it doesn't sound like they're ignoring symptoms... it sounds to me like the new plan is to use the existing symptom-taxonomy but not the existing condition-taxonomy (ie, the groupings of symptoms into conditions). So they'll be looking for eg quantifiable measures that correlate with anhedonia (symptom), not depression (condition).
posted by jamjam at 3:48 PM on May 4, 2013 [2 favorites]


From the article:

* A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
* Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
* Each level of analysis needs to be understood across a dimension of function,
* Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.


1. I agree doing all this would result in better treatment.

2. Doing all this would take ten times the resources at least that they use now to devise a DSM label for you, write a scrip, and file the forms for your insurer.
posted by bukvich at 5:03 PM on May 4, 2013


I worry that this will bio-essentalise ambigious work, pushing attempts at neuro-diveristy, into an explicitly medical model. I mean we are doing that anyways, but still...
posted by PinkMoose at 5:07 PM on May 4, 2013 [2 favorites]


LobsterMitten: "3.2.3, it doesn't sound like they're ignoring symptoms... it sounds to me like the new plan is to use the existing symptom-taxonomy but not the existing condition-taxonomy (ie, the groupings of symptoms into conditions). So they'll be looking for eg quantifiable measures that correlate with anhedonia (symptom), not depression (condition)."

That's how I read it too, and I think it's mostly a good move from a research perspective. As I understand it, the DSM criteria represent a current best guess as to how mental disorders should be organised. I think it's handy to have something like this for pragmatic purposes: without a diagnostic category for "depression", I imagine that it'd be difficult to include antidepressants on things like the Pharmaceuticals Benefit Scheme.

The issue that NIMH seem to be getting at is that we shouldn't be making too much of the DSM criteria for research purposes, and it might be counterproductive to rely on them. If you have some biomarker that is reliably correlated with a particular pattern of symptoms that doesn't happen to correspond to a DSM category, it seems silly to reject the biomarker. Yet this is currently what happens (or so sayeth NIMH), presumably because it's easier and simpler to analyse data in terms of "depression" (a single binary outcome variable) than in terms of the various symptoms (a larger number of outcomes with a messy pattern of correlations among them).

I guess my worry with their proposed RDoC approach is that it could easily ossify into something just as problematic as the DSM. At the moment, they just have their 5 "major research domains", and it's vague enough that it's easy to write around, but you can see some quirks in them already: does really it make sense to treat "Cognitive Systems" as a different domain to "Systems for Social Processes"? Should cognition be isolated from "Positive Valence" and "Negative Valence"? And so on. The more that this RDoC starts to turn into its own set of pre-specified research categories, the more it starts to move away from a bottom-up, "lets just see what we can learn from the pattern of symptoms" approach.
posted by mixing at 5:10 PM on May 4, 2013 [1 favorite]


It's pretty easy to hate on the DSM, but the situation before it was also mess. I highly recommend reading Of Two Minds , which goes through the history of psychiatry in American and why the DSM was made and why the decisions were made.
posted by roguewraith at 5:27 PM on May 4, 2013 [1 favorite]


While we're on book recommendations about the making of the DSM, this book by Kirk and Kutchins, about the politics that went into selling the DSM-III, is really excellent.
posted by painquale at 5:38 PM on May 4, 2013 [1 favorite]


Biological theory of mental illness fundamentally goes wrong when it assumes that symptoms are a sign the biology is doing something WRONG.

The biology might be doing something different but that doesn't mean it's doing the wrong thing.

If your spouse died yesterday your brain would look different that if your spouse didn't. It doesn't mean your brain is doing the "wrong" biological processes. The biology might be doing exactly what it should be doing. Making you feel like shit.

That there is biology involved does not mean we are talking disease requiring a medical solution.
posted by xarnop at 6:06 PM on May 4, 2013 [6 favorites]


I would like to add we DO need solutions, but pharma needs to get out of dominating the market on types of therapeutic services, social policies, societal structures, and interventions for difficulties people face. Therapy is a joke as it right now because it doesn't address deeply rooted biological processes, however pharma doesn't respectfully heal or assist the body in returning to health either. Therapy also doesn't address structural inequality, poverty, poor nutrition, inadequate exercise/sunlight/clean air, abuse, toxic exposures, occupations that are damaging to physical and mental health- or many of the other experiences people can be trapped in that are making their mental health worse. We can work at these things form many different angles and it's just gross that we've let ourselves be convinced that our emotional well being comes only in the form of pills.
posted by xarnop at 6:12 PM on May 4, 2013 [5 favorites]


I think LobsterMitten's reading of this is perhaps going a little too far - I don't think they are making some kind of manifesto about materialism here, they are rather talking in the context of biological research, and, in that context, it doesn't seem alarming that they are going to go ahead and assume that they are looking for biological things.

These people are doing medical research, not philosophy, and I am sure they know this. We don't require physicists to, say, resolve all the metaphysical problems about causality before they can get to work, and I don't think it's reasonable to think that neurobiology people have to address objections from all possible forms of non-materialism before they get to work. The arrogance and glib optimism of some people who do that kind of work isn't doing them any favors with respect to generating goodwill and understanding, of course.

It may be that I am ignorant of the implications for funding of other kinds of research, though - maybe this is more ominous, from the point of view of people who don't do hard-ish science work in psychology, than I am taking it to be.
posted by thelonius at 6:24 PM on May 4, 2013


I don't think they are making some kind of manifesto about materialism here

Yeah, no - to be clearer, I don't think there was an intent to stake out a position on the philosophical question per se, but for people who work on the philosophical question this is a really interesting development. And I do wonder how much this is anticipating a change in general public's intuitions about the relationship between mental conditions and physical conditions as we learn more.
posted by LobsterMitten at 6:31 PM on May 4, 2013 [2 favorites]


Grief is not a mental illness.
posted by elizardbits at 6:42 PM on May 4, 2013 [8 favorites]


I can see how it would be indeed interesting!

As a stray remark, I've grown wary of the very popular hardware/software analogy to explain the mind-body relationship. It's a great metaphor to start thinking with, but it has very little content, and I have seen people literalize it too far so many times. Would it not be a remarkable coincidence if the human brain and mind turn out to work just like a von Neumann stored program computer, for example?

I also note that there has been a long trend of trying to explain humans in terms of the currently dominant technology. It's now of course computing, but I think people even tried this with the kind of industrial control systems that cybernetics studied, and, of course, in the 19th century and before, as a mechanical contraption of some kind that resembled the new technologies of the time. This makes me suspect that the object of the technology metaphor is not the important side.....
posted by thelonius at 7:09 PM on May 4, 2013 [2 favorites]


"Grief is not a mental illness."

Yet it is treated as such in the DSM.

Too much mourning and you're on the psych meds! Two years of abuse? Psych meds! Diagnosis of being mentally ill!

What's more when you look into the physical problems that stress and trauma and poor environmental variables cause- there are some physical problems in the brain and body that we could use medical knowledge of to help people recover.

That said, some of the processes we observe in those who are traumatized, developmentally delayed, or experienced childhood environments that didn't meet their physical or emotional needs are biological in nature but they are repairative and alterations designed to assist with coping with the variables in a persons physical body and environment. Sometimes the body is doing good things to cope with altered environmental and developmental variables. To wipe out the entire process is to essentially damage some of what it means to have a human life and developmental history and repair process that allows the body to maintain the knowledge of itself and it's experiences.

I know many people with mental illness get threatened by the idea of rethinking the medical model as THE ANSWER, but it really really does not mean people in need of support should be abandoned or that their needs aren't very real. We can reframe what the needs are and how to meet them without labeling people as defective if they actually aren't.
posted by xarnop at 7:28 PM on May 4, 2013 [2 favorites]


xarnop: ""Grief is not a mental illness."

Yet it is treated as such in the DSM.
"

But is it? If this summary is to be believed, the diagnostic criteria for major depression in DSM IV explicitly exclude bereavement from the depression diagnosis.
posted by mixing at 7:34 PM on May 4, 2013 [1 favorite]


DSM V is different.
posted by xarnop at 7:35 PM on May 4, 2013


I would be super psyched if this thread didn't derail into whether medicine should be used to treat health problems.
posted by shakespeherian at 7:38 PM on May 4, 2013 [8 favorites]


To quote Mr. Vitabellosi, "Positivists always win, because they're religious about it."
posted by vitabellosi at 7:42 PM on May 4, 2013 [2 favorites]


This thread is specifically about diagnostics which is how doctors and scientists are given the right to define for everyone else what is or isn't a medical health problem. It's extremely political and related to doctors and researchers and professionals preconceived notions and personal bias/interests how they define these things and rarely are those variables innately in the interests of the actual people being labelled or not labelled and treated as mentally ill or treated as a human with valid emotions and experience of reality.

It's perfectly relevant.

They ARE defining grief as a mental health problem. We can't think that's fucked up?
posted by xarnop at 7:45 PM on May 4, 2013 [1 favorite]


I hadn't seen the DSM V change. That feels like a radical redefinition of depression. The DSM IV version seems to treat depression as something that involves "inappropriate" (scare quotes intentional) negative emotions. The DSM V version seems to shift towards the idea that any time one feels "sufficiently" bad, even if it's for perfectly rational reasons, then this counts as depression. I've got no problem with having a word for the DSM V version, but it no longer feels like you can call it a "disorder".

Actually, this makes me even more in favour of the NIMH proposal. If I were trying to identify correlates of "depression" in a study, I'd be pretty annoyed at the way DSM V defines it. Ignoring the diagnostic criteria and working at the symptom level seems to be a quite simple way for basic research to avoid the issue.
posted by mixing at 7:52 PM on May 4, 2013 [1 favorite]


If you exercise you have biomarkers in your body after. You could say that this is a "medical problem" because it's biological. There are symptoms, you might be out of breath or experiencing other physical symptoms that something is different. You could put medicines in the body to remove the biomarkers because it's different than normal and therefore bad. You are then innately interfering with the bodies healing processes after exercising.

Emotional processing is a physical process. The fact that it has biological correlates does not mean the solution is to medicate those correlates into being the same as other peoples.

If someone has gone through a childhood where their emotional connection and sense of support/nurturing wasn't working in their family, their biology might look different. It developed differently.

This doesn't mean that forcing their biology to look like normal people's is the right solution. Cab drivers have different brains than non- that doesn't mean they have a disorder, or that they need their brains to be biologically altered to look like normal people.

The NIHMS model will hopefully allow us to pursue research along these lines of how different experiences, family dynamics, diets and toxic exposures, air quality, allergens and substances in the home, physical illness, chronic and latent infections, hormonal imbalances and various physical health problems correlate with actual lived experiences and exposures. We can also trace the biology of restorative experiences and health supports such as diet and exercise, talk therapy, recreational and social activities, training activities to work in areas of physical and mental difficulty, targeted nutritional support, occupational and physical therapy techniques, bodywork, and research in creating therapeutic environments and what biologically is restoring health and what isn't.

We're no where near ready for the NIHM model to be ACCURATE in the way the goal is, but I think it's much more realistic in terms of assessing what is going on in the body (whether that is defined as a "disease" or simply a process that could be supported in specific ways). It certainly opens doors to study the body itself and various means of supporting overall health and well being, instead of the art of obsessively throwing pills at people and labeling them as ill based on whether the pill makes them feel better. And more accurate means of supporting people who think differently, function differently, or are coping with a heavy load of emotionally difficult life variables.
posted by xarnop at 8:28 PM on May 4, 2013 [4 favorites]


xarnop: If you exercise you have biomarkers in your body after. You could say that this is a "medical problem" because it's biological. There are symptoms, you might be out of breath or experiencing other physical symptoms that something is different. You could put medicines in the body to remove the biomarkers because it's different than normal and therefore bad. You are then innately interfering with the bodies healing processes after exercising.

Well, to be fair, because grief is extrinsic to the mind doesn't necessarily mean treatment would be a bad thing. An open fracture is extrinsic, but medical treatment for it is more desirable than letting the body heal naturally.

I'm not necessarily saying that treatment is better for sure, mind you, only that the possibility that it is can't be discarded out of hand.
posted by Mitrovarr at 8:52 PM on May 4, 2013 [2 favorites]


If you exercise you have biomarkers in your body after. You could say that this is a "medical problem" because it's biological. There are symptoms, you might be out of breath or experiencing other physical symptoms that something is different. You could put medicines in the body to remove the biomarkers because it's different than normal and therefore bad. You are then innately interfering with the bodies healing processes after exercising.

But normal is not what we're looking for nor is it a precise thing. For instance "normal" human body temperature is 98.6 degrees F. But we know that body temperature can vary greatly from person to person and even during the day the body temperature goes up and down by a degree either way. The point is that when you do empirical testing to find medical problems there's usually an acceptable range for these things to take based upon previously experienced values and any factors affecting the patient currently. This acceptable range is what we should be looking for.

If there's no problem behaviour there's obviously no reason to be alarmed. But if someone has a manic episode and we can pin down quickly just what's out of whack in their brain and treat them correctly we can skip the five to ten year clusterfuck while psychs struggle to diagnose and treat based on trial and error and their own "gut feeling".
posted by Talez at 9:14 PM on May 4, 2013


The article is offensive in its scientistic ideology. The second paragraph sophistically, disingenuously analogizes mental disorders to physical ones. The third explicitly claims that "Mental disorders are biological disorders involving brain circuits…". That is not only a pretty uneducated statement coming out of a supposedly scientific institution, but also disturbingly fascistic in its rhetorical framing. If you were a real scientist, you would have begun your inquiry by understanding such assumptions in the first place.

This is only happening because is inevitable that the mental health industry conflates "teching up" with progress—and that's all that is being proposed here. In their narrow purview, they are trying to sell better, improved medicines and "methods" as The way to fix the problems of the mind. In problem solving and research, there is the classic parable of the streetlight fallacy. Some of these people need to escape their groupthink and read something like The Conduct of Inquiry: Methodology for Behavioral Science, Kaplan 1964.

Here is a recent thesis out of Australia:
This conceptualisation of psychological suffering was referred to as the ‘Dysfunctional Mind Account’ (DMA), and in Chapter One it was argued that this conceptualisation underlies all accepted models or theories of psychological suffering and is the dominant way of conceptualising such suffering for both professionals and lay-people in Western cultures. / It was argued in Chapter Two that this conceptualisation is inherently flawed at a theoretical level, and has very little empirical support. It was further suggested that, at a practical level, such a conceptualisation leads to the search for both causes and ‘cure’ being focused primarily ‘inside the skin’ of the individual; a partial approach which leads to only partial and often misleading results. This approach not only compromises our understanding of such suffering, but also compromises our efforts to prevent and to ‘cure’ and/or alleviate such suffering.
So how about these doctor-scientists try to exercise some actual critical thinking for a change.
posted by polymodus at 9:17 PM on May 4, 2013 [4 favorites]


If you have some biomarker that is reliably correlated with a particular pattern of symptoms that doesn't happen to correspond to a DSM category, it seems silly to reject the biomarker.

But also very dangerous to evaluate a proposed treatment on whether it moves the biomarker, surely.
posted by escabeche at 9:26 PM on May 4, 2013 [1 favorite]


xarnop: "It certainly opens doors to study the body itself and various means of supporting overall health and well being, instead of the art of obsessively throwing pills at people and labeling them as ill based on whether the pill makes them feel better."

I often hear this kind of generalization about mental health care in the US, and to be fair it's what I used to believe as well before I ever had experience with it. But at one point I found that I could no longer rely on my own coping methods to get me through and turned to professional help. It was the best decision I have made about my own health and has lead to significant improvements in my life, along with some revelations and adjustments. I see a psychiatrist and have not had the experience of her "throwing pills" at me; rather I take a single medication for one diagnosis and am working with a therapist to deal with another, and this is after a lot of progress and working through other stuff. My diagnoses are valid, IMO, inasmuch as treating them has been beneficial to me, and in no way have my experiences left me feeling like mental illness diagnoses or treatment demeans or diminishes me as a person.

However, I have found the opinions of other people who have zero qualifications to diagnose me or to provide a professional perspective on my own experiences with the mental health profession to be sometimes very confrontational and irrational. I feel this antagonism towards mental health care only serves to stigmatize and further marginalize people with mental illness, who may be able to find the help they need more easily if they aren't discouraged from doing so, and this includes financial and social pressures. I can only speak for myself, but this kind of thinking was the biggest impediment to my seeking help for a long time and didn't serve me well for all the years I wasted believing it.
posted by krinklyfig at 10:16 PM on May 4, 2013 [10 favorites]


I do want to emphasize that my therapist and psychiatrist have both been interested in my health on the whole. Part of my therapy includes exercise, diet, sleep, etc., normal health maintenance in other words. In my case it happens to be very beneficial to treating my conditions. I know not all practitioners do this, but the idea that they all use a very narrow and entirely pharmacological approach to treating mental illness is misleading at best. However, if I didn't feel comfortable with my treatment and didn't trust my providers, I would seek out help elsewhere.
posted by krinklyfig at 10:24 PM on May 4, 2013 [1 favorite]


escabeche: ""If you have some biomarker that is reliably correlated with a particular pattern of symptoms that doesn't happen to correspond to a DSM category, it seems silly to reject the biomarker."

But also very dangerous to evaluate a proposed treatment on whether it moves the biomarker, surely.
"

Absolutely. "Biomarker" is definitely not synonymous with "cause".
posted by mixing at 3:26 AM on May 5, 2013 [1 favorite]


I won't be satisfied until DSM-VI defines hamask as a valid issue. (I am not kidding about this, I am speaking from very real first hand experience, and much too recent, alas).
posted by symbioid at 6:41 AM on May 5, 2013


elizardbits: "Grief is not a mental illness."

No, it's not. But you have to look closely at the terms. Remember, one reason why DSM is "clinical" is at the end of most of its symptom shopping lists, there's the 'must cause reduced functioning for x length of time' or 'must be perceived as a subjective or objective problem'. Without this, it's just observation lists. With this, it's a clinical manual to guide treatment. In this, it's no different from manuals in many fields of clinical medicine.

Back to the terms. "Disease" is what we say something is when we see a pathology, and we a pathophysiological response. Or in the absence of an identifiable etiology, we see the pathophysiology, or the symptom cluster. We call that disease. "Illness" is the person's response to a disease, and this is where individual responses vary dramatically. For grief, some of the symptoms associated with grief involve anhedonia, anorexia or hyperexia, mood depression, guilt, insomnia or hypersomnia, confusion, intrusive thoughts, delusions, hallucinations, movement retardation and suicidality. Sometimes, these persist for surprisingly long periods of time. And when we start calling something an "illness" is when it starts interfering with a person's ability to function, to live, beyond what we as a society or culture deem acceptable. I've seen people in prolonged depressions, that started with simple grief, so ill they are smearing feces over themselves, week after week, or trying to kill themselves, not eating and literally starving to death, incredibly psychotic and delusional and sometimes threatening through action or inaction their children or relatives.

I call that an illness, and I'm going to try to help those people. Of course, not all grief advances that far. But we know some of the biomarkers, and behavioral signs, and neuropsychology, and neurobiological and imaging correlates associated with prolonged mood depression. And many of them are indistinguishable from prolonged grief. Ironically, under the new NIMH model of symptomology and correlates, it seems like it will be easier to lump disparate diagnostic entities such as complicated grief, chronic lyme, unipolar affective disorder, chronic fatigue, complex GI, etc.
posted by meehawl at 7:29 AM on May 5, 2013 [2 favorites]


symbioid: "I won't be satisfied until DSM-VI defines hamask as a valid issue."

Intermittent explosive disorder
Dissociative disorder
Amok
etc
posted by meehawl at 7:35 AM on May 5, 2013 [1 favorite]


Sounds like no more Scylla, we want more Charybdis, isn't it ?
posted by nicolin at 7:51 AM on May 5, 2013


Eternal Sunshine of the Spotless Mind. Worth a watch.
posted by srboisvert at 8:10 AM on May 5, 2013


What always slightly boggled me about the DSM is that, unlike any other medical field, psychiatry ends up changing ALL of its diagnostic guidelines at once, instead of piecemeal (eg, you get new criteria for heart disease one year, and then emphysema another, etc). Makes for an awful headache for shrinks.
posted by demons in the base at 8:38 AM on May 5, 2013


so, who gets to be called crazy now

is there any way we can just cut the fat and print out a list of who gets screwed and in what ways
posted by This, of course, alludes to you at 9:15 AM on May 5, 2013 [1 favorite]


This is not the revolution in psychiatry we need.

I saw this video a few months back. In it Thomas Insel talks about "Mental Disorders as Brain Disorders".

Insel is, with what are perhaps the best of intentions, reinforcing a cultural argument about "mental illness". The assumption is this: much human suffering has individual, biological causes. And the cause is in the brain. I keep seeing this rhetoric from well-meaning people, and whenever I do, I get chills. I truly believe this assumption that most mental illnesses are "brain disorders" is unscientific and distorts both research and treatment.

I've been diagnosed with depression. I want good science. And while biology certainly plays a role, I feel that Insel's perspective completely ignores the possibility of cultural and social causes of suffering and disordered thinking. Social isolation, abuse, poverty, stress, sleep deprivation, lack of sunlight or exercise... the list of potential external causes of mental illness is huge. But they're largely ignored in favor of a perspective that puts the blame squarely on some characteristic of the sufferer's brain.

Compare with obesity: An increasing percentage of Westerners are overweight. Is it because everyone suddenly has a dysfunctional metabolisms? Is it because there's something wrong with our biology? Or is there a complicated relationship between biological risk factors, poor diet, and sedentary lifestyle? And why can't mental illness work the same way?
posted by Wemmick at 10:49 AM on May 5, 2013 [4 favorites]


Remember, one reason why DSM is "clinical" is at the end of most of its symptom shopping lists, there's the 'must cause reduced functioning for x length of time' or 'must be perceived as a subjective or objective problem'. Without this, it's just observation lists. With this, it's a clinical manual to guide treatment. In this, it's no different from manuals in many fields of clinical medicine.

That's been contested. Some analyses purport to show that normative terms like the ones you mention are not normally part of diagnostic criteria in non-mental-health related branches of medicine. You don't need to ask a person whether their life is impaired in order to identify a heart murmur or a broken tibia or a tooth cavity.

Of course, whether a condition makes it into a diagnostic manual in the first place might be sensitive to the extent to which it tends to impair peoples' lives. But that is different from saying that the impairment in itself is a diagnostic criterion. In other words, you can ask two different questions about a broken bone: is it broken, and is it bad that it is broken? It's not clear that there are two similarly distinct questions to ask about depression.
posted by painquale at 11:45 AM on May 5, 2013


Is Psychiatry Dishonest? And if so, is it a noble lie?
posted by painquale at 4:04 PM on May 5, 2013


painquale: "You don't need to ask a person whether their life is impaired in order to identify a heart murmur or a broken tibia or a tooth cavity."

These are good examples of the debate between the phenomenology vs noosology of medicine. These things you list, are they severe enough to cause a reduction in functioning? A loss of optimality? Is there morbidity? That's why one of the most important questions you ask someone is "What brings you to the ED|office|hospital today"? Is your objective finding a root cause of a perceived loss of function? Will fixing it improve functioning? What if the risk/benefit calculation? What is the risk of a false positive and a false negative. Then you get into questions of capacity to accept and reuse treatment, which exist in all areas of medicine.

The same question applies to "depression". People sometimes tell me they're depressed. The key questions are what does depression feel like to them, how long have they felt like this, and what do they think could change this? The cases I listed earlier, where I have literally had patients starving to death or trying to kill themselves or others, are extreme. But what if someone says their "depression" has caused them to fail at establishing stable long-term loving relationships? That's a harder question address, and treatment options are more difficult. Sometimes the best thing to do is nothing.
posted by meehawl at 4:40 PM on May 5, 2013 [1 favorite]


painquale: "you can ask two different questions about a broken bone: is it broken, and is it bad that it is broken? It's not clear that there are two similarly distinct questions to ask about depression."

On reading this more closely at the end, I see you addressed my earlier concern. But there are indeed different questions to ask about "depression". For instance, people with the behavioral symptoms usually labelled borderline personality may be flagged as depressed using a simple state question model, and with enough of the symptoms to reach MDE Severe categorisation. But the DSM has a grab-bag of symptoms to define the trait, which more or less operationalise the psychological dysfunctions usually attributed to that behavior pattern (affective dysregulation, impulsive-behavioral dyscontrol, cognitive-perceptual distortion). We now know a lot more about the specific pharmacotherapy and talk/group/behavioral therapies with a higher (or lower!) probability of success for the specific sub-types of borderline, and we know that, for instance, conventional antidepressant pharmacotherapy for major depressive disorder only has a probability of effect beyond placebo for very specific categories of MDD and in particular populations. And unless they're in the BPD sub-type characterised by a proportionately large, stable affective depression, antidepressent pharamcotherapy (as opposed to mood stabilisation or antipsychotisation) is unlikely to be effective, and may in fact be destabilising. But every patient is unique, and the probabilities are aggregate, and guide therapy without being deterministic. This is no different than other non-emergent diagnostic/treatment decisions in medicine, such as which maintenance asthma medication to choose (if any) and on what dosing, or whether to treat something like mild hypertension and with which agent. Frequently I am faced with someone with a maladaptive personality, who wants "an adjustment" in their medications, because their "depression" has worsened, and they want treatment (and often they're attached to the notion of their "depression" as a biochemical imbalance). There's a whole bunch of questions waiting to be asked there involving loss of function, mortality risk, progress and character before making any kind of informed decision as to whether to offer a treatment change. This is no different than a patient with advanced COPD, saying their shortness of breath has worsened. It may indeed have on objective measures, or their subjective sense of it has intensified. It's a tough call, and the decision to treat or not based on fungible boundaries is not really unique within medicine to psychiatry.

Or using your bone example, especially with MRI, I can find lots of, say, older people with mild hairline stress fractures and tissue tears. These may be causing discomfort, or they may be sub-clinical. Treat or not treat? Often times an orthopeaedic doc will make a decision to use some specific therapies with limited evidence bases, such as platelet rich plasma, and the decision to treat (or not) involves not only medicine but a bunch of other factors.

That's actually one of the problems, raised earlier up-thread, with the idea that the NIMH's proposed research category markers should guide clinical treatment. If I take a big sample of people, especially pro-bands of people with diagnoses such as schizophrenia and bipolar , I can test them and find significant divergences from "normal" in terms of genetics, fMRI, social environement, EEG, neuropsychological testing, and post-mortem on neuropath histology. But they have no diagnosis, and many of them function well within a "normal" range. Do they need to be treated? That's why the "impairment" stipulation exists in the DSM.
posted by meehawl at 5:15 PM on May 5, 2013 [2 favorites]


Yeah I don't agree with NIMH or the DSM. But that's just from 15 years of experience being diagnosed and "treated" for better or worse before I started doing my own reading into the research being done and found the professionals don't even themselves understand it. The fact that individuals testify and swear passionately by the truth of psychiatry and it's life changing value proves no more than the testimonies of those who have been healed and psychologically repaired by our lord jesus christ who are also passionate and certain in the truth and validity of their way.

Placebo is awesome and clinically significant. I don't care if individuals feel better taking pills, I care when people who don'tunderstand the science behind what they are doing, or really respect the depth of the human experience outside a medical model, and that defines what services I get when I need help.

That's when others individual beliefs start to bother me. I'm not going to take anyone's meds from them, I just don't want a society that makes it imposable for me to get help in any form other than pills and labels of being a disorder for feeling different than others about life and functioning outside the normal parameters of what we expect of people in this society.

An example, SPD is commonly used as a diagnosis to work with kids and the methods work really well. Many adults with the same problems wind up progressing to worse mental health problems because they didn't start respecting their needs sooner and tried to fit in a way of functioning or exposures that were overloading and not working for their system. I think many adults are misdiagnosed and undereducated about what services might really help them function and what work and school accommodations would really meet their needs.
posted by xarnop at 5:58 PM on May 5, 2013 [1 favorite]


I just don't want a society that makes it imposable for me to get help in any form other than pills

Man what are you even talking about.
posted by shakespeherian at 8:23 PM on May 5, 2013 [1 favorite]


I don't think that's an entirely unreasonable fear. Pills are cheaper than basically any other intervention, so that's generally what insurance companies will prefer. And it's easier for a doctor to prescribe a few pills than figure out if there's some chronic problem in the patient's life that's leading to suffering instead of a biochemical issue.
posted by Wemmick at 8:56 PM on May 5, 2013


The fact that individuals testify and swear passionately by the truth of psychiatry and it's life changing value proves no more than the testimonies of those who have been healed and psychologically repaired by our lord jesus christ who are also passionate and certain in the truth and validity of their way.

What? I assume you feel this way about people taking medications for heart disease, diabetes, chronic pain, etc.
posted by sweetkid at 8:59 PM on May 5, 2013 [3 favorites]


Heart disease, diabetes, and chronic pain have objective diagnostic criteria and well-understood causal models. Plenty of mental "illnesses" don't. Which is not to say that they don't involve genuine suffering - simply that a disease model may be inappropriate. We keep saying that we'll figure out the causes of depression, anxiety, etc., real soon now. Just more research, better imaging, and we'll figure out what's wrong with their brains. But we'll only find something if the brain is where the real problem lies.
posted by Wemmick at 9:07 PM on May 5, 2013 [1 favorite]


I know people with chronic pain who would disagree that their illness is understood. And putting mental "illness" in quotes and dismissing it as religious belief is really insulting to the people who are struggling today.

Also, people with so-called "physical" diseases often end up having mental issues that emerge along with their disease. I agree we have a lot to learn about the brain, but acting like people with mental illness don't need medication or their actual experience is worthless hocus pocus is dangerous and insulting. Before the pills we had electroshock, or institutions, or jail for people with mental illness. It's been here forever, the pharmaceutical industry did not invent it.
posted by sweetkid at 9:12 PM on May 5, 2013 [3 favorites]


Handwaving away the medical reality of mental illness because clinical depression is hard to pin down is kinda silly given that mental illness also incorporates schizoaffective disorder and a whole heap of things that no one confuses with having a bad day at work.
posted by shakespeherian at 9:17 PM on May 5, 2013 [4 favorites]


No... I don't mean to diminish the experiences of people suffering. What I do believe that the cause of that suffering is not necessarily individual or biological in nature. Again, stress, poverty, abuse, social isolation, are all frequently ignored in favor of an assumption that the source of the distress is in the brain.

Nor would I argue that medication is necessarily useless. Some people clearly do find it helpful. But that's not evidence for biological dysfunction either - it could be that medication is a chemical method of coping much like alcohol or other substances. Pills don't have to actually fix things to make life easier for people.
posted by Wemmick at 9:19 PM on May 5, 2013 [1 favorite]


Ok, I agree with a lot of what you just said. But there isn't necessarily a bright line between mental illnesses and ones we consider to be in the physical realm. Treating the brain with medication is still treating the body. But yes because people are helped by medicine isn't proof that the medication is what they need, if that's what you're saying I agree with you.
posted by sweetkid at 9:24 PM on May 5, 2013


My brother-in-law suffers from schizoaffective disorder. It runs in his family--his uncle had it, his great uncle had it. I'm already worrying that my son--who is four months old on Wednesday--will have it. My brother-in-law started developing symptoms in 2001. He's been living in hospitals and group homes for years, now. A few years ago he wandered away from a group trip and walked up to the top of a five-story parking garage and jumped off because he needed to make the voices stop. He survived but then climbed out of the hospital window and jumped. Luckily that was only from the second floor.

They've found medication that works, now, and he's living in a better facility that watches him and makes sure he's taking his pills instead of hiding them under the mattress. When he started taking these there was concern because there's a chance that they can thin his blood enough to kill him, but fortunately that didn't happen. Now when I talk to him he isn't scarily distant, he isn't talking to me about conspiracies between pharmaceutical companies and the government, he isn't trying to self-medicate with ginko baloba because he read on the internet that it's just as good. Now when I talk to him, he's Andrew again.

But his face is now shaped like someone who fell fifty feet onto concrete. I'll never be able to forget what 'just as good' means.

Medicine is good. Mental illness is illness. If doctors had not found this treatment for my brother-in-law, I would no longer be able to talk to him in any form. But I can. Because doctors. Because science.
posted by shakespeherian at 9:31 PM on May 5, 2013 [4 favorites]


I'm glad they've found something to help your brother-in-law. I don't know about specific disorders - it's entirely possible that schizoaffective disorder has strong biological components we don't fully understand. But science is only as good as its assumptions, and I think we're missing a lot by saying that we can find the cause for everything by examining the biology of individuals while ignoring the effects of the world they're embedded in.
posted by Wemmick at 9:40 PM on May 5, 2013 [2 favorites]


xarnop: "Yeah I don't agree with NIMH or the DSM. But that's just from 15 years of experience being diagnosed and "treated" for better or worse before I started doing my own reading into the research being done and found the professionals don't even themselves understand it."

But this is true of "physical" medicine as well. There is still an awful lot involved in medical treatment that is based much more on outcomes than understanding all of the underlying mechanisms. As we learn more about those mechanisms it opens new doors, but in medicine we used what worked long before we knew why.

"Placebo is awesome and clinically significant. I don't care if individuals feel better taking pills, I care when people who don'tunderstand the science behind what they are doing, or really respect the depth of the human experience outside a medical model, and that defines what services I get when I need help."

In my case, the medication I'm taking is known to have a specific effect on brain chemistry, effectively making up for what's missing due to my condition. It's not a placebo at all. I'm not sure how to address the rest of what you said except that your experience has not been the same as mine, although at one point we did share the same perspective. I am sad for you that you have struggled with your attempts to heal for so long.

I had to learn how to be my own advocate to get what I needed to deal with my own mental health issues, and in no way were all the answers handed to me on a platter or ever as simple as taking a pill to feel better; it was more like a long hard slog to healing, but the same has been true of my experiences with health care in general. There's a lot that could be improved, but in my case I had to accept that the people who were treating me were also doing the best they could, or that I should be seeking help elsewhere if I didn't believe that to be the case or if it wasn't working for me. Giving up on this work or viewing it as a struggle between me and the world was no longer an option, nor was believing that I knew more than the whole of the mental health establishment. I still feel the need to be in control of the decisions, but I had to accept help before I could find it helpful to me.
posted by krinklyfig at 10:57 PM on May 5, 2013 [1 favorite]


"Giving up on this work or viewing it as a struggle between me and the world was no longer an option, nor was believing that I knew more than the whole of the mental health establishment."

You're right, we shouldn't question the professionals because as history has shown us, they have never been wrong about systems of medical thought, or social theory, or the methods and societal structures that will promote, sustain, and heal human beings before.

What's more, the whole of the human conditions, what it means to grieve, to grow up with poverty or abuse, to grow up with systemic racism or sexual abuse, or stigma, to grow up in a family that doesn't understand you-- all of these things are better understood and defined by professionals rather than individuals who live them.

What's more if you have chronic sinus infections for half the year and you just want to sleep all day, don't ever question the doctor when they think the chronic fatigue is the result of depression that needs to be medicated immediately and don't question it when the meds then give you panic attacks and anxiety and the doctor decides that means more mental health diagnosis and more meds!

That's crazy conspiracy think right there. Weirdos.
posted by xarnop at 7:41 AM on May 6, 2013 [1 favorite]


xarnop I feel like you're not reading anything anyone is writing here, just typing pills are bad over and over. Also the sarcasm is making your point hard to understand. Of course patients should be educated about their treatment and ask questions, but that doesn't mean that mental health care and psychiatric treatment is garbage.
posted by sweetkid at 7:53 AM on May 6, 2013 [3 favorites]


sweetkid- yes there's a lot of good to work with. I've been finding in psych classes that the teachers themselves are very uneducated about neurobiology and physical health and it's relationship with brain, mood, and psychological states.

Apologies for the sarcasm. I really would love it if more people would read the current research so that we could actually discuss what really makes sense. I think I just long for fellow human beings who are educated about mental illness, neurodiversity, they difference and how to support various types of people with different needs, in our social structures, family and peer groups, schools, work environments, and life in general. It's exhausting that the popular preconceptions of mental health issues involve assuming that people who function differently need to be medicated and have no recourse against that even if various types of meds make them more sick.

But for now I'll just accept that communities don't accept non-neurotypical people who aren't medicated in general and live with the stigma. Perhaps if I can finish a degree in neurobiology and better explain the research I have been reading among people in the general public it might be easier for people who are different but better off not on meds to be accepted by general communities and the professionals who assist them.

Psychotic disorders do benefit from medication in some instances but the research does find that less is more in terms of future recovery- not the common mantra that more is more- or that not taking meds is always bad for anyone who has dealt with pscyhotic, bi-polar or other serious mental health issues.

I think it's understandable that the general public tends to presume a mentally ill person not on meds is unstable because often they go of meds without the appropriate support structures to do so safely and to be monitored and supported through the process. If professionals were more knowledgeable about non-pharmaceutifcal techniques with clinical efficacy, we could offer people who don't want to be on meds better options to do so without having a breakdown or endangering themselves or others (or merely making everyone around them miserable).

I'll try to rethink how I approach the topic in future threads so as not to come across as too sarcastic or that I'm not reading what others say- which I am. I believe that many people have been helped by the mental health system as it is and that is good, but a lot of people I know are using it and not getting better and I think there are some wrong decisions being made and lot's of opportunity to improve how we think about emotional and psychological wellbeing and how to integrate and support non-neurotypical people- both in improving biological understanding and in opening up the doors of medical solutions based in a wider range of solutions that psychpharma-- such as treating underlying physical conditions in the body, working with allergies and infections, changing our school and work systems from standardization to accommodate different personality and skill sets- creating better avenues for people to address problems in their family and peer systems (such as bullying, isolation, neglect, abuse). There are so many multifaceted ways to improve brain health and mood including physical activity, clinical nutrition, and targeted exercises and activities to strengthen areas of weakness and I just think even professionals are so closed minded in the avenues they seek to support people, and the types of research they work on and perfect for clinical medical use. (This is the case for physical health conditions as well.)

There's tons of research ALREADY indicating a lot of avenues of treatment with clinical significance for medical use, so I'm still talking evidence based medicine, I just think the idea that means immediately the medicine needs to be a pill is limited thinking that does sometimes hurt people who could have better forms of treatment. (Just as giving someone an exercise plan when they needed a pill can be harmful and life threatening and is equally malpractice perpetuated by the woo industry that refuses to clinically evaluate it's efficacy.)
posted by xarnop at 8:34 AM on May 6, 2013 [3 favorites]


Maybe reading about environmental enrichment might shed light on the kind of research I've been reading about and want to see applied to mental health treatment protocols, and family support infrastructures (to help families address the creation of an enriching and fulfilling environment that supports healthy development and family relationships).

I think what I say doesn't make sense because I'm resisting the urge to link to 10 bazillion research articles I've been reading about how to create and facilitate brain health and physical/emotional well being in families and human habitats. There is a lot of research that indicates we've got our noses all up in excess understanding of pharma but neglecting a lot of research already being done indicating policy changes, public education and access to different types of supports for families (and individuals) to facilitate mental and emotional health, and a variety of activities and methods to alter and promote the course of mental health conditions that are not being applied when they could be.

If you think about it, we have better science at the art of raising health trees than raising healthy humans and a lot of the lack of access to the right supports is both a poverty issue and lack of education/awareness issue. A lot of the techniques that facilitate healthy development are common instinctual behaviors in functional/healthy families. A lot of what erodes health is being in harmful working conditions, and being too poor afford enrichment to balance the harmful effects or to get a job that matches your individual needs. Or being the child of a parent trapped in such conditions which will limit the ability of the family to either provide or pay for environmental enrichment and nurturing connected activities. Or being the child of a parent conditioned to accept and perpetuate unhealthy rearing conditions even when the funds or opportunities to provide more love, connection and healthy enrichment becomes available. The abusive parent doesn't feed the child rice because there's no other option, they feed the child only rice because "it was good enough for me and it's good enough for you! Shut your trap about a growling belly and get over it! That's life!"

Learning how to retrain and heal brains through environmental enrichment, social interaction and other forms of healing activities is something that needs clinical research because not all "healing activities" as sold actually provide therapeutic healing to the brain, and different types of people with different conditions will respond differently to different types of environmental variables. It's extremely important when selling people healing that you have consulted the science extensively to examine efficacy and are selling something that appears to actually create meaningful healing.

I'm not as anti-pharma as I sound, but on examining the wealth of resources we could be offering people to create and maintain health, I feel we would be needing to use it much less frequently and more sparingly if we actually used the rest of the research we already have to make our habitat human health friendly.
posted by xarnop at 9:27 AM on May 6, 2013 [3 favorites]


Welp
posted by shakespeherian at 9:32 AM on May 6, 2013 [1 favorite]


I disagree with you with that non-pharma solutions are non medical. Evidence based medicine can come in many forms. But I'll leave this thread be.
posted by xarnop at 9:34 AM on May 6, 2013


xarnop: "But for now I'll just accept that communities don't accept non-neurotypical people who aren't medicated in general and live with the stigma."

:-/

Well, I don't find that works out any better for me medicated than it did before. I'm still pretty much a misfit. I'm much happier embracing this as my nature than trying to act neurotypical, as you say. This is one reason I live where I do, because this place is kind of a long-standing freak magnet, and there's a lot of us here (although the work situation in a rural area like this is likely going to force me to move soon). However, I was always really bothered by my actual neuroses and the way my behavior was affected by it in ways that were seemingly beyond my control. I can handle being a fringe person or a paste eater just fine, but being neurotic and anxiety ridden is a big ball of shit. The only way I could work through that was to go the conventional mental health route, although my providers are flexible and can offer many options, rather than being stuck inside some box dictated strictly by diagnostic models. And this is at a community mental health "crisis" center, not private practice.

Honestly, it's not easy, I have been lucky in finding the help I needed without too much seeking once it came to that point, and I know plenty of people who have tried and tried for years and only seemed to find dead ends in therapy. This kind of journey can be traumatic in itself. I sincerely hope people have more rather than less options to deal with their own mental health, and if this encourages that while allowing for pharmacological treatments for those of us who find them useful or necessary, then I'm OK with it. But if it becomes a way to dismiss the work that's been done and the real benefits that some of us have experienced, that doesn't seem so great.
posted by krinklyfig at 11:30 AM on May 6, 2013 [1 favorite]


xarnop: "Psychotic disorders do benefit from medication in some instances but the research does find that less is more in terms of future recovery- not the common mantra that more is more- or that not taking meds is always bad for anyone who has dealt with pscyhotic, bi-polar or other serious mental health issues. "


Extraordinary claims demand extraordinary evidence.

There are two major EBM studies concerning outcomes and choices of antipsychotic type and dosage that may be of interest, CATIE and CUtLASS. The takeaway message is that except for clozapine, there's no majorly significant different in therapeutic outcomes between the (cheap) 1st and (expensive) 2nd generation antipsychotics. By these trials, when it comes to medication effectiveness, the most effective medication is one a person is willing to take, and the most effective dosing schedule is regularly. And placebo or no treatment has very poor relative efficacy.
posted by meehawl at 6:52 PM on May 6, 2013 [1 favorite]


Extraordinary claims! This is tough because of paywalls but ok. You're looking at 2-3 year studies. I'm talking about long term as in, the persons entire life.

this this on global outcomes

this
"However, evidence on long-term (10 or more years) efficacy of antipsychotics is mixed. Double-blind discontinuation studies indicate significantly more relapses in unmedicated schizophrenia patients in the first 6-10 months, but also present some potentially paradoxical features"

this
"Despite the proven efficacy of antipsychotic medications over the short term, there is a subgroup of schizophrenia patients who, a few years after the acute phase, function adequately or experience periods of recovery for a number of years, without treatment. "

Also a lot of research about medication use or nonuse is really a study of how ill or responsive to treatment the person is to begin with. Medication refusers at onset of symptoms tend to be more resistant to ANY form of intervention and more ill. If you're asking whether I've read a lot of research on this subject, the answer is yes and we could discuss research on the matter for a long time.
"Poor premorbid functioning, comorbid substance use, and poor insight predicted both medication refusal and nonadherence; a forensic history and no previous contact to psychiatric care were specifically predictive of medication refusal."

They don't do placebo trials in the long terms so there are not any good long term studies of people kept on a placebo for 20 years (which for obvious reasons would be unethical).

this
"In the context of emerging evidence regarding the overestimation of the effectiveness of antipsychotics and the underestimation of their toxicity, as well as emerging data regarding the possibility of alternative treatments, it may be time to reconsider the prevailing opinion that all service users with psychosis require antipsychotic medication in order to recover. "

"These results show that the majority of the subjects had maintained their recovery, and that subjects who are still fully recovered have not used medication for seventeen years and are more resilient. Thus, a sustained, full recovery without medication seems possible for a subgroup of schizophrenia patients characterized by high resilience."

Also of note:
"In other words, antipsychotics may have become popular because they’re the treatment for people who can’t afford anything better.

These data show that antipsychotics were over twice as likely to be prescribed to African American patients; the poor i.e. patients with public health insurance; and children under 18."
posted by xarnop at 3:40 AM on May 7, 2013 [2 favorites]


For the most part, these are low quality observational trials, with limited power, and this one does not even say what you think it says. It's not even clear when you look at global labels such as "schizophrenia" that different cultures are talking about the same disease -- we can't even be sure reading the Euro/US literature from 50 years ago that we can reliably distinguish between "bipolar" and "schizophrenia" (one of the modern benefits of the DSM!). Your global study update points out that whereas "clinical" outcome rates are lower in developed countries, functional outcomes are better. That screams to me observer and selection bias - we have more surveillance in developed countries, therefore we have more longitudinal follow-up. Therefore we detect residual disease with greater sensitivity. and because we do, we achieve better functional outcomes.

xarnop: "They don't do placebo trials in the long terms"

Your long-term placebo trial outcomes await you sleeping furtively in public parks the world over.

xarnop: "full recovery without medication seems possible for a subgroup of schizophrenia patients characterized by high resilience.""

Your "sub-groups can be med free" paper says nothing surprising. Yes, schizophrenia is a grab-bag term for a whole bunch of disease processes with similar phenotypes, and it's a continuum disease. Some of them have a single flare and then abate, others relapse and remit in a pattern more like multiple sclerosis. And like MS, the full disease spectrum is massively under-diagnosed. Some people on the milder end, or without regular flares, can do well without meds, or with meds only during periods of flare. Others mask their psychosis with adaptations such as extreme somatization, or culturally sanctioned social isolation. Others have families rich enough to afford extraordinary measures such

Your regression analysis for med refusal predictors applies, as you indicate, to pretty much all medicine. So I.m not sure of a point specific to psych meds.

Your "patient choice" paper echoes my analysis of CUtLASS: it's not really that important which antipsychotic you choose and their relative efficacies do not seem strong enough to come out even in large RCTs. The most important med is one within the class that a person is willing to take, and that's pretty much it. Basic research shows that if you can achieve serum levels that result in CNS penetration to achieve at least 80% dopamine-2 receptor blockade, then your probability of causing clinically significant remission in acute psychosis becomes maximally greater than placebo (which is itself around 50% for a first break) and anything above 80% receptor blockade shows a ceiling cutoff in effectiveness. That's why it's rarely effective to dose someone too much, if what you are trying to address is psychosis. Of course, people get more heavily dosed for a bunch of others reasons, but that's not really for psychiatric medicine.

Your other sub-group paper also says there's a small subset of people that can remain sufficiently functional without meds. Again, no real surprise for a heterogeneous disease with variable course and a continuum of severity. We see the same thing with MS, or asthma, or hypertension, or lupus, or a whole bunch of chronic diseases. And the super-mild "schizophrenia" cases that never get tagged as such, we label them things like paranoid personalities, or delusional disorders, or schizotypal or a whole bunch of really quite bizarre and atypical conversion and parasitosis and delusionally somatized diseases that you really only see if you work in a tertiary care hospital.

Your "more drugs for poor people" is sadly true, and reflects a social malaise more than an inherent weakness of therapy. It's being driven largely by regulatory capture and the economics of health insurance. Again from CUtLASS, there's absolutely no valid reason why large payers and States should be forking out 10-100x for newer antipsychotics when old ones run so cheaply. But they are being sold the ideal that these newer boondoggle drugs work better and, again, looking at the cost of treating chronic patients over several years, it remains staffing and location costs that are highest. Even though the wholesale drug cost difference between narcotizing someone on a cheap first-generation antipsychotic versus something ridiculously well-marketed such as Abilify or Saphris can be 100-100x, by the time you factor in drug delivery costs for high-acuity patients, the difference is usually only 1-2x. And becomes a rounding error beneath the cost in terms of QALYs and staffing. Others have covered much better how programs such as SSDI are used as medicalized poverty balms.

But here's the thing. If you have enough money, you can avoid drugs and swing for regular, intensive residential treatment including psychoanalysis for things like schizophrenia and borderline. It works pretty well for some people, and eliminates the med ADRS and harm. But the number of people who can utilize this is so low, and they are so far removed from most of your predictors for treatment failure, that their chance of a good outcome anyway is elevated.
posted by meehawl at 9:24 PM on May 9, 2013 [1 favorite]


So, meehawl, where do we differ? I'm advocating for patient choice to be given the opportunity to achieve stability while not on meds which many mentally different people do.

You are arguing against giving mentally different people this opportunity or respecting mentally different people who have not found meds useful or found them harmful?

Are you? Or what?
posted by xarnop at 2:27 PM on May 10, 2013


It also irks me something awful that people claim that these disorders are set "diseases" in themselves. If a person has fatigue and swollen lymphs the symptoms cluster me be a disease but it is not THE disease. It could be anything.

Abnormal brain functioning can be caused by so many different physical problems that the structures we're using to talk about them are ridiculously out of touch with the science of the human body which is the one reason I'm in favor of NIMH.

At least if some sect of the population is going to lord over and define another, they should at least understand the physiology by which they're being granted this power.
posted by xarnop at 2:30 PM on May 10, 2013


"But the number of people who can utilize this is so low"

I know it's bizarre to think we could create a system that actually matches best services for mentally different people instead of cheapest and easiest- but I really think if this is a better treatment option we should be working to make it available to all people who need care that best matches their actual needs and gives them the most opportunity to make as full a recovery as possible.
posted by xarnop at 2:36 PM on May 10, 2013


I don't know if "mentally different" is supposed to be more respectful than "ill" but it doesn't seem to come across that way to me.
posted by sweetkid at 2:38 PM on May 10, 2013


Yeah it's a little grating personally TBH.
posted by shakespeherian at 2:39 PM on May 10, 2013


Well I support individuals using whatever term they like. I choose my term, others can choose there's. If talking to a specific individual about their specific condition, I'm happy to use their preferred term.
posted by xarnop at 2:45 PM on May 10, 2013


That's super but at least in the context of this discussion it's coming across-- to me, at least-- as kinda handwavy about whether individuals have actual medical problems that can and should be dealt with in a medical fashion.
posted by shakespeherian at 2:50 PM on May 10, 2013 [1 favorite]


yea, or are they just different, you know, some people have schizophrenia or depression like some people have curly hair or dimples. Takes all kinds, man.
posted by sweetkid at 2:52 PM on May 10, 2013 [1 favorite]


sweetkid- I recognize perhaps you are defensive because you think I am threatening your right to medical care and social support of your choosing and respect for your medical choices?

You're threatening mine, that makes me threatened and angry too.

I'm not interested in taking from you your definition of yourself or medications that help you (or others). I just find that current definitions of mental wellness often take that from me.

I support more research because look, we do not MEDICALLY understand what is going on with the physiology of these symptoms clusters or the various reasons they are coming up or how to address those reasons.

But yes, you got me, I think trauma and developmental trauma are normal responses to abnormal circumstances.

I also think that people who have been raised in unhealthy environments will show signs of disease or "abnormal" functioning. And there are better ways to fix that than obsessively testing pharmaceuticals in them.
posted by xarnop at 3:04 PM on May 10, 2013


You're threatening mine, that makes me threatened and angry too.

How am I doing that?
posted by sweetkid at 3:14 PM on May 10, 2013


[Xarnop, it may be time to take a step back from this thread a bit, you're getting pretty dug-in. ]
posted by restless_nomad at 3:15 PM on May 10, 2013


Psychiatrists under fire in mental health battle: British Psychological Society to launch attack on rival profession, casting doubt on biomedical model of mental illness
posted by homunculus at 4:05 PM on May 12, 2013


homunculus: "Psychiatrists under fire in mental health battle: British Psychological Society to launch attack on rival profession, casting doubt on biomedical model of mental illness"


At its core, the APA exists to publish a raft of specialist publications and one of them, the DSM, has become quite important to lot of people. Which is where a lot of the ruction seems to emerge from.

The BPS also has an extensive publishing operation. But it's got nothing with nearly the influence of the DSM. For this round of the DSM, I think the more psychologically and research-oriented groups lobbied hard for more trait-based and quantitative screening +/- psychometric measures to be included in the DSM's core diagnostic categories. The APA field tested a bunch of these and apparently rejected many of them as either inconclusive or not worth the extra effort/cost in terms of workload vs improving patient care.

I reference a lot of the BPS stuff, mainly through EBSCO, and it's got some great stuff, but their membership are not medical doctors and their approach to treatment of people who present with diseases lacks a certain "medical" approach. That's why DSM is a "clinical" manual.
posted by meehawl at 7:31 PM on May 12, 2013


You Do Not Have Asperger’s: What psychiatry’s new diagnostic manual means for people on the autism spectrum.
posted by homunculus at 10:51 PM on May 22, 2013


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