Wednesday, February 17, 2010

My DSM-5 Report Card: Grading Depression - Part III

This concludes my three-part DSM-5 Depression report card, my answer to the DSM-5 draft proposals issued last week ...


Is there a place in your house you dread looking into? The attic? The crawl space? A certain closet? The bottom of your refrigerator? The current DSM contains its own version of the dreaded place. It is called NOS - not otherwise specified - and accompanies 41 listed diagnoses.

The draft DSM-5 would continue the practice. I peeked in and, suffice to say, experienced every traumatic flashback involving attics, crawl spaces, closets, and refrigerators, and then some. Some background:

If you’re a DSM editor and don’t know what to do with a certain type of symptom or behavior, you create an NOS closet (or refrigerator) and stick the weird stuff in and close the door. Maybe you’ll figure out what to do with it later.

It you’re a doctor and don’t know how to diagnose a certain patient, you write up NOS and find the appropriate closet (or refrigerator), shut your eyes, stick it in, and close the door. Maybe you’ll come up with the correct diagnosis later.

The trouble is NOS is a black hole. What, for instance, does “Depression NOS” mean? Imagine “Cardiovascular NOS” and you can see that the practice is unacceptable, whether one is practicing medicine or writing a diagnostic manual. Moreover, the practice is highly abused. A background paper put out by the DSM-5 mood disorders workgroup cited an unpublished study that found that the specialist and nonspecialist clinicians in the sample employed “NOS” in 37-38 percent of their primary diagnoses for depression.

The DSM-5 would change NOS to CNEC (conditions not otherwise classified). I opened the freshly painted closet door to find ...

Subsyndromal depressive CNEC. This would include patients in obvious distress who somehow don’t meet the formal diagnostic criteria for depression. Given the extremely wide view of depression the DSM already employs and its generously low thresholds it’s hard to imagine such a group. Certainly there are those who must put up with residual symptoms once the worst is over, but can’t we find a better way of defining this category? Out in broad daylight?

Major depressive disorder superimposed on a psychotic disorder
. What the hell is something this major doing buried away in a closet?

Recurrent brief depressive disorder
. So THAT’s where they stuck highly recurrent depression! I was looking all over for it. Nope, not out with recurrent major depressive disorder, where it belongs. Nope, not red-flagged as a type of depression closely related to bipolar. Nope, stuck away in a closet.

PMDD. Are you kidding me? We still hide “women’s problems” in the closet?

The sad thing is the things lurking in the DSM-5 CNEC closet are nearly identical versions of those still gathering dust in the DSM-IV NOS refuse bin.

Grade: F-minus

To Sum Up

Thus concludes my three-part DSM-5 Depression Report Card. Here are the subjects and my grades:
  • Symptom Checklist: F-minus
  • Mixed Anxiety Depression: C
  • Mixed Episodes: Incomplete
  • Chronic and Recurrent Depression: F
  • Severity: Incomplete
  • The Specifiers: F
  • Reactive Depression: F-minus
  • Personality (extra credit): No grade
  • NOS: F-minus
Overall grade: F

Concluding Remarks

One of the ironies in issuing this report card is that I owe much to virtually all of the members of the DSM-5 mood disorders workgroup. I have read their articles. I have heard them speak at conferences. I have asked them questions face-to-face. In some cases, I found myself seated at the same breakfast or luncheon or dinner table.

My dealings with these individuals have been extremely productive and beneficial. To a person, they are as dedicated to their work as they have been gracious to me. Moreover, a good deal of what I know about mood disorders can be attributed to them and their colleagues. Many of my key Aha! moments are a direct result of the wisdom they have shared with me, their professional colleagues, and with patients and family members.

So, what went wrong?

For one, DSM-5 operating parameters were far too restrictive, involving an onerous burden of proof for new inclusions. Too often, the necessary empirical data was lacking. We may “know” for instance that depression is bound up in personality, but can we “prove” it?

Scientists need to “validate” their claims with scientific evidence. But what if the picture they produce is inaccurate and misleading and leads to the kind of absurd results I've brought up this series? No acknowledgment of the obvious relation and overlap between depression and bipolar? C'mon!

My concern is with "credibility," which the DSM-5 sacrificed in its obsessive over-pursuit of "validity." As a result, the DSM-5 is failing in its key mission of aligning psychiatric authority to our clinical reality.

Nevertheless, everyone has a stake in the status quo - Pharma, the insurance companies, the clinical-research establishment, perhaps even patient advocacy groups. Credible or not, the DSM pays the bills. Thus, no one is about to stand up and say the DSM-5 is a piece of shit. Okay, I just did, but who listens to me?

The other main problem is “paradigm freeze,” which I will get to in a future blog piece.  

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet. But after that, I will move straight to personality disorders, where I foresee much higher marks.

Coming up: My DSM-5 Bipolar Report Card ...

From the My Report Card series


Bloodthirsty Warmonger said...

That irritating abbreviation NOS reminds me of the days when cartographers used to write on the margins of maps about areas they sincerely knew nothing about, "here lie dragons." IMHO, the taxonomy of depressive and bipolar disorders is oversimplified and leads many practitioners to adopt a cookbook approach to identifying the many flavors of mental illness.

Charles M. Sakai

Anonymous said...

Living with years-long (six now) crushing, immobilizing, mentally debilitating, solitary, want-to-die daily, every single moment is excrutiating, clinical depression is something these folks (Working Group) do not want to hear about. Sure my primary diagnosis is correctly Bipolar. But my Psychiatrist is unmoved, and is content (resolved?) with my condition because I have not made the move to suicide but once (at the very beginning). I have personal control over the daily urge to die. If she (the patient) is alive then its OK. No it is not! You people with the power to help diagnose and point to real issues that affect many many lives - get on to the real work with the DSM and start helping people heal!!! Not good enough. The meds are a true gamble, and no one really understands how/why (IF!) they work. But you need to be clear that untreatable Bipolar clinical depression is unacceptable and must be treated. Am I clear enough here?

John McManamy said...

Hey, Anonymous. I hear you loud and clear. I strongly recommend seeking out another psychiatrist, one who listens.

Willa Goodfellow said...

Sheesh, John -- I'm in a downhill snowboard race, and have just been passed midair! [I know how you do it -- you're bipolar, but how do they?] Anyway, there is still hope that my blog will post what looks like an original thought next week. If you continue through the DSM V as thoroughly as you have begun, I'll take my shortcut and might beat you at the finish.

Not that this is a competition, of course. ;-)

John McManamy said...

Hey, Willa. I'll tell you one sport where you won't find any bipolars - golf! According to facts I'm making up as I'm going along, bipolars account for more lost balls and broken clubs than all the rest of humanity combined.

Now hurry up with your own DSM-5 analysis. It's lonely out here. :)