Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud

I finally finished reading Shrinks, and I submitted a 1 star review to Amazon, with the heading, "Painful to read, misleading, and with no insight into its own deficits. Don't buy it! Don't borrow it! Don't read it!" The following is not what I wrote on Amazon, but it's related.

I've given a lot of thought to how I want to write this full review (see my partial review here). Shrinks is an excruciating rant-sneering, caustic, and just so wrong in so many ways. It was tempting to just shred it point by invalid point. But the truth is, there's something pathetic about the lengths to which Lieberman goes to "prove" that his version is the only true psychiatry.

So I decided to focus on my real concern-the impact this book may have on a lay audience. This is where I think it's downright dangerous. Lieberman writes about present day psychiatry as though it's already achieved all the goals it aspires to. He speaks as though current brain imaging has already explained the etiology of all mental illness, and as though DSM has classified every possible psychiatric disorder: 

...the book precisely defines every known mental illness. It is these detailed definitions that empower the DSM's unparalleled medical influence over society.


He writes about the wonderful breakthroughs that Thorazine, lithium, and imipramine represented-and I agree that these drugs were godsends to many people, but he includes virtually no information about the problems that these and other meds can cause, or about the fact that they don't always work. To hear him tell it, biomarkers are already in widespread use and predictive of treatment response in many psychiatric illnesses. And most of all, his version of psychiatry is, wait for it, SCIENTIFIC.

As I read Shrinks, I tried very hard to imagine what it would be like if I were a reasonably intelligent adult with no particular knowledge of psychiatry, but who was interested in learning about the field. (Okay, cue the jokes about my being reasonably unintelligent and questionably adult)

It's an unrealistic thought exercise, but I imagine I might think I'm reading a book by someone who is an expert in his field, chair of psychiatry at a prestigious hospital, former president of the APA, so he must know what he's talking about. I'm pretty sure I wouldn't be familiar with the immensely varied modes of thinking that exist in psychiatry. I suspect I'd assume psychopharmacology and psychoanalysis are areas that all psychiatrists are trained in. And since Dr. Lieberman is a psychiatrist, psychoanalysis must be part of his field, so if he's claiming there's no validity to it, he must be telling the embarrassing but necessary truth. And if he claims drugs and CBT are effective and "scientific", he must be right about that, too. 

I hope I would pick up on the painfully disparaging tone, and the fact that sneering does not constitute evidence, but I'm not sure I would. 

At some point, I realized I didn't need to speculate about what a layperson would think of the book, I could, instead, read reviews on Amazon. And it turns out that, for the most part, it got good reviews from people outside the field, and bad reviews from people who know something about psychiatry, or its history. Here are some examples, both good and bad:

April 12, 2015
Shrinks by Dr. Jeffrey Lieberman is a fantastic read and a real eye opener for those of us who know next to nothing about psychiatry...The bottom line is that Shrinks brings to light many myths about psychiatry, but it also points out its historic shortcomings. More importantly it presents mental illness not as something to be ashamed of or for which there is no cure, but rather as a medical condition just like any other which can and should be addressed with proper treatment. Thankfully the advances in neuroscience and psychiatry, reviewed by Dr. Liberman in his book, have enhanced the understanding of the causes of mental illness and vastly improved the methods of its treatment.

April 1, 2015

...In his book, Dr. Lieberman clearly offered his experience as a scientist and physician and the history of psychiatry...The best parts of the book describe the rise and fall of theories championed by Freud and how they stymied real science and the description of the motivation behind some of organized psychiatry's most barbaric practices...

Dr. Lieberman explains so well the past failures, the research being presently done and the future of psychiatry. What an honest book...

Lieberman tells this story with remarkable clarity, complete honesty about his own viewpoint, and unusual humility for someone in the field. The human mind, whether it functions well or ill, is poorly understood, but recent progress in both understanding and treatment is significant...but most importantly, there is help.. the right help and the exciting future with DNA exploration...

This top psychiatrist says his field of medicine has recently turned a corner and he shows how it is offering real help to those with anxiety, eating disorders, phobias, obsessions, PTSD, bi-polar disorder, etc. And for people facing brain issues like Parkinsons, autism, Alzheimers, etc, scientists are getting oh so close.

March 28, 2015

I'm biased. I am a historian of psychiatry. Really. I have a PhD from the University of Michigan, served on the faculty of the University of Chicago, and wrote a book on the history of psychotherapy. ...So arrogant as this may sound, I know what I'm talking about. This book is compendium of errors -- at least from a historian's perspective. It fails to consider virtually all of the scholarship produced over the past fifty years on the subject, cites virtually no primary sources, and simply recycles common stories -- many of which have long since been discredited....this book does an extraordinary disservice to those who have been producing exceptional scholarship in the field for decades. What's more, it reveals how easy it is for a well-respected (and deservedly so) physician to publish nonsense about a subject about which he knows little and has probably read even less....You might not agree with me. But I can promise you this: I did my homework. That's not something Dr. Lieberman can say. What's more, I didn't pay someone to write my book for me.

Self-promotion at its worst...and most dangerous

March 22, 2015

To read this book, you would think that everyone who was treated with psychotropic drugs was miraculously cured and anyone who was not sunk into misery or worse. There is no mention of the millions of prescriptions written to treat questionable disorders for children as young as two, or of the terrible side effects of the some of the powerful medications that Dr. Lieberman evidently eagerly dispenses to virtually every patient who walks into his office. You would further conclude that no one was ever helped by psychoanalysis, nor for that matter any other form of therapy than his. This is a book filled with half truths, omissions, distortions, and propaganda. The "untold story of psychiatry" indeed.

In my earlier review, I wrote that I was willing to buy into the historical information included in the book. I stand corrected.


The basic outline of the book is this: first we had "alienists", who oversaw the care of the mentally ill in institutions, even though there was nothing much to be done for these patients. Then Freud came along and treated the "worried well" with what we now know is a bogus treatment designed by Jews and for Jews (not clear to me why Lieberman emphasizes that particular point, but he seems to feel it's important). Beginning in WWII, a taxonomy of mental illness was finally! developed, by an analyst, no less, and this ultimately led to the DSM-III, the savior of psychiatry. Then meds came along, and brain imaging, and CBT, and more recently, genetic markers. And today, psychiatry can proudly state that it understands the etiology of mental illnesses, and has the tools to successfully treat them. 

The book's argument reminds me of people who understand evolutionary process to mean that living beings have maintained a progressive course over eons just to reach the pinnacle of existence that is humanity. 

Lieberman never explains why the things he sneers at are unscientific. He just states it as fact. He has no understanding or knowledge of, nor does he make any reference to, psychoanalysis as it has been practiced and understood for the last 30 or so years. His bio on the Columbia site indicates that he is a, "Physician and scientist," so it's hard to understand why he doesn't even attempt to give a factual basis to his assertions. 

And he seems completely unaware of his own internal contradictions. He criticizes psychoanalysis for blaming family members for a patient's illness, such as the idea of the "refrigerator mother" in autism, or the "schizophrenogenic mother". 

But then he goes on to describe several of his cases, in which his recommended treatment failed because of the patients' families, who he criticized. 

I told them quite bluntly that their decision to withhold treatment was both cruel and immoral-though tragically, not illegal...

Lieberman seems to think that only his recommendations matter, and once he's made them, there's no need to establish a rapport with a patient's family, in order to help the patient. They should just do what he says because he's right. 

He has no clue about the limitations of the DSM, which he refers to repeatedly as "The Bible of Psychiatry". He's convinced that everything in the DSM is "scientific", despite his own descriptions of how many of the decisions about its content were made-often as compromises and to reassure the public and get proper insurance reimbursement.

He thinks that knowing there's an amygdala-hippocampus-prefrontal cortex loop in PTSD explains why people get PTSD. He claims that some people have genetic differences that predispose them to PTSD, and that's why some get it and some don't.
He proudly describes two traumatic experiences of his own-his apartment was invaded and he was robbed at gunpoint when he was in medical school, and 12 years later, he accidentally dropped an air conditioner out of his 15th floor apartment window. No one was hurt in either incident, but he was not traumatized by the former (the robbery), and had some PTSD symptoms following the latter (the air conditioner). Obviously, he can't claim his genetic predisposition changed in the intervening 12 years. Instead, he comes up with a long-winded story about how he had the illusion of control when being robbed, but not when dropping the air conditioner and that created a different amygdala loop. It never occurs to him to ask WHY he had the illusion of control in one situation but not the other. He has no sense that the two events had different meanings for him. And it certainly doesn't occur to him that HE was the aggressor in the incident that gave him PTSD symptoms.

Meaning, for Lieberman, is meaningless. All that matters are symptoms and getting the diagnosis right.

I'm trying not to harp on this part, but another truly dangerous aspect to the book is the way Lieberman disses any type of talk therapy that isn't CBT. Especially psychoanalysis. Here's some of the language he uses:

Gradually, physicians came to recognize that focusing on unobservable processes shrouded within a nebulous "Mind" did not produce lasting change...

...Sigmund Schlomo Freud stands in a class of his own, simultaneously psychiatry's greatest hero and its most calamitous rogue. (Incidentally, Freud's accurate birth name was, "Sigismund", not "Sigmund")

Freud ended up leading psychiatry into an intellectual desert for more than half a century...

As a psychiatrist who lived through many of the worst excesses of the psychoanalytic theocracy, I regard Freud's fateful decision (to discourage scientific questioning) with sadness and regret.

(On the move of many early analysts to American due to WWII): These psychiatric refugees would soon change the fundamental nature of mental health care in the United States, but not necessarily for the better. They brought with them the dogmatic and faith-based approach to psychiatry that Freud had espoused, discouraging inquiry and experimentation. Eventually,...psychoanalysis would become a plague upon American medicine, infecting every institution of psychiatry with its dogmatic and antiscientific mind-set...
...By 1940, American psychoanalysis had become a unique phenomenon in the annals of medicine: a scientifically ungrounded theory, adapted for the specific needs of a minority ethnic group (Jews).

Knowing that the path to influence ran through medical schools and teaching hospitals, psychoanalysts began targeting universities.

Had it been able to lie upon its own therapeutic couch, the psychoanalytic movement would have been diagnosed with all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.



Talk about projection!


Psychoanalysts  and psychoanalysis are compared to or described as:

omen-divining wizards

the primeval sorcery of the jungle witch doctor

the circus Big Top

a mangled map of mental illness

the psychoanalytic hegemony

The Oracle of Delphi

I get a definite sense of a man with no tolerance for ambiguity or ambivalence. 

He writes about his college experimentation with recreational drugs, which involved his researching which drug would be the best for him, before going on to try it. This is clearly not a guy who dropped acid because someone offered him some at a party. 

He idolizes Robert Spitzer for creating the DSM-III. He relates an anecdote in which a teenage Spitzer, at summer camp, was confused about his feelings towards girls, so he made charts of those feelings and kept them on his bunk wall. This is viewed, in the book, as a demonstration of Spitzer's great promise as a researcher, not as an indication of a highly intellectualized defense.

Lieberman also dislikes the notion that mental illness exists on a spectrum, that there is no clear defining line between sickness and health, and he feels this was one of Freud's great mistakes:

It was no longer acceptable to divide human behavior into normal and pathological, since virtually all human behavior reflected some form of neurotic conflict, and while conflict was innate to everyone, like fingerprints and belly buttons, no two conflicts looked exactly alike...the psychoanalysts set out to convince the public that we were all walking wounded, normal neurotics, functioning psychotics...

No wonder the DSM-III had such great appeal for these men. When Lieberman writes about the standing ovation Spitzer got when the DSM-III was approved, it feels like a conquest, like he has vanquished the evil empire established by Freud, the community from which he was excluded for his "scientific" beliefs, and the sun is finally beginning to shine on psychiatry. 

The title of this post was intended to be provocative, but there really is an Oedipal victory feel to the book. As you can tell from the quotes above, there's a lot of disparaging comparison of psychoanalysis to magic or religion, along with some comments that flirt with antisemitism, but then he keeps calling the DSM the "Bible of Psychiatry". Apparently, his is the better religion.

Lieberman, (or maye it's Ogas) writes with particular vehemence about the period when most psychiatrists did analytic training. It made me wonder if he was rejected from a training program at one point, or if he was in an analysis that he quit because he found it intolerable. I have absolutely no basis for these thoughts- they're just conjecture. But here's the description:

Think about that for a minute. The only way to become a psychiatrist-a bona fide medical professional-was to share your life's history, innermost feelings, fears, and aspirations, your nightly dreams and daily fantasies, with someone who would use this deeply intimate material to determine how devoted you were to Freudian principles. Imagine if the only way you could become a theoretical physicist was to confess an unwavering and unquestioning dedication to the theory of relativity or the precepts of quantum mechanics, or if the only way you could become an economist was to reveal whether Karl Marx appeared as an angel (or devil) in your dreams. If a trainee wanted to rise within the ranks of academic psychiatry or develop a successful practice, she had to demonstrate fealty to psychoanalytic theory. If not, she risked being banished to working in the public-hospital sector, which usually meant a state mental institution. If you were looking for an indoctrination method to foster a particular ideology within a profession, you probably couldn't do much better than forcing all job applicants to undergo confessional psychotherapy with a therapist-inquisitor already committed to the ideology.

Nowhere does he indicate that he has even considered the possibility that understanding ones own limitations can make one a better clinician. He doesn't even seem to get that if one is caring for patients, it might be helpful to know what it's like to be a patient. And forget the idea that an analysis is intended to be helpful. He seems to view it as nothing but a threat. The analyst as, "therapist-inquisitor".

Reading the paragraph above, it really is hard to believe Lieberman's claim that he likes psychoanalysis. 

The final concern I have has to do with Lieberman's inability to imagine that other people may not think the same way he does. Here's a quote:

...a psychoanalytic diagnosis of Abigail Abercrombie might account for her spells of anxiety by connecting them to the way she reacted to her parents' strict Lutheran upbringing, combined with her decision to leave home at an early age to work rather than marry. A Kraepelinian diagnosis would characterize Abbey as suffering from an anxiety disorder based upon her symptoms of intense fear and discomfort accompanied by heart palpitations, sweating, and dizziness, symptoms that occurred together in regular episodes.

Lieberman obviously believes that the analytic approach is wrong, and the Kraepelinian approach is right. But leaving aside the issue of which is correct (and why can't there be some of both?) I feel like he's assuming everyone prefers to have his internal

experience described by symptoms and their duration. There's no sense that some people might prefer his way, but others might prefer to have their experiences of anxiety considered in the context of a fuller narrative of who they are, with some continuity to how they got to be this way. Some might even find it offensive to be reduced to a bunch of symptoms and a diagnosis code. 

And unlike Lieberman, some people might be comfortable with a little ambiguity. 

Reference:
J Am Psychoanal Assoc. 2015 Apr 24. pii: 0003065115585169. [Epub ahead of print]
The Psychiatrist, Circa 2015: "From Shrink to Pill-Pusher".
Hoffman L. PMID: 2591090

K'vetch Fest 2.0

First off, let me apologize for the radio silence. I've been on vacation, literally and figuratively, and I haven't been able to get myself to so much as look at a draft of a post, let alone work on one, or even read the usual blogs I follow, with the exception of my favorite crochet blog. That's how mindless I've been keeping things.

Mea culpa.

Moving on, I'm going to pick up where I left off on a post I started before vacation.

In the mid-70's, the comedian Alan King had a TV special called, "Final Warning", in which he joked about everything that was wrong with the world. The next year, he had another special called, "2nd Annual Final Warning", and the year after that, "3rd Annual Final Warning."

It's been a year since I wrote The Culture of Medicine and the Art of Kvetching, in which I asked the age-old question, "How did we get to this place?" And I listed a few of the things that make practicing psychiatry a crazy endeavor. And I know crazy.

Last year's list, in brief:

DSM-5
E/M coding
I-STOP
MOC
HIPAA
EHRs
Insurance Companies
SAFE

Well, a lot has happened in the past year. The concerns that plagued me then have evaporated, while other woes have befallen me. Here's a partial list of what's bothering me now:

MOC
ERx
EHR's
Collaborative Care Model
ACA
Insurance Companies
+/- ICD-10
DSM-IV vs. DSM-5 on the board exam
Big Pharma not releasing data
HIPAA

Oh, wait. I guess not that much has changed, after all. E/M doesn't bother me anymore because I use a template for notes, which make my notes completely meaningless, and I'm pretty much on autopilot. In fact, I'd have to reread my own post if I wanted to remember the nitty gritty of coding.

The NY SAFE gun act that is supposed to prevent the "dangerously mentally ill" from obtaining access to firearms has simply not been relevant in my practice, and I hope it never becomes so. And I-STOP is now I-Just Do It and I-Don't Care.

Beyond that, it looks like things have gotten worse. HIPAA is still on my list because now it's not clear if doctors who prescribe electronically, which will be all doctors starting in March, are subject to HIPAA. I got a letter from my risk management about this the other day. They're researching the eRx issue, and they also sited cases where there were breeches of security because some management bozo left 70 boxes of medical records out on the street. Ya think?
They also wrote about the lack of security for those who somehow still use Windows XP, now known as Windows RIP. Mac rules!

EHR's are still worse than useless, and the CDC has been actively pursuing me to get my opinion on a "brief" and "voluntary", but not "anonymous" survey. Seriously, I mean stalking. I got one copy of the survey, which sat on my desk while I contemplated whether I would fill it out. A week later I got a postcard reminding me to fill it out. That's when I placed it in the circular file. I've since gotten two more copies of the survey, and two irritated phone calls.
I thought about filling the thing out. It asked about whether and how I use an EHR. I had some qualms about chucking the thing because if I'm really concerned about the use of EHR's, then I should fill out the survey and express my opinion. But it didn't really provide a way for me to describe the fact that I have an EHR, but I don't use it, and the only reason I have it is because I don't want to have to pay a lot of money to e-prescribe, come March. It also wasn't anonymous, and asked some stuff related to meaningful use that seemed like a good excuse for private insurance companies, in the not-too-distant future, to reimburse less for doctors who don't use EHRs, consistent with medicare/medicaid policy. And they were a little cagey in their description of how the information was to be used.

I thought I was good with the Erx situation, but it turns out I need to re-verify my credentials. And I may have used up the three chances I get to do so, because I started the process at work, and then realized the answers to some of their questions involving old mortgages and addresses were at home. I'm gonna try again, but if it doesn't work, I'm not sure what I'll do in March.

The Collaborative Care Model makes me want to cry-I have half a post written about it, so maybe I'll share that if I can finish it. And I don't understand why no one of importance has come out and stated that the reason Big Pharma is withholding its data is because they're worried that if they reveal the full data, people will realize that their drugs either don't work, or are harmful. Or both.

But the big one, of course, is MOC. I registered for my exam today. I put it off as long as I felt I could tolerate, but I finally bit the bullet and did it. All $1500 of it. I did read through the terms pretty carefully, and even though I've agreed that the board can decide my test results are invalid, even if they don't think I did anything wrong, I did notice that that particular clause does not say anything about my needing to pay to retake the exam under those circumstances. It doesn't say I don't need to pay, either, but at least I can make an argument for myself. Yup, that's how positive I'm feeling about the experience.
And a few days ago I ordered the cheapest version of DSM-5 that I could find. That would be the Desk Reference to the Diagnostic Criteria from DSM-5(TM) (Paperback), which set me back $26.27, as opposed to the $62.02 spiral-bound version. It's sitting in an unopened box on my desk, along with a bottle of granite cleaner. I felt like there was no way I could figure out the changes from IV to 5 without seeing 5. But it pains me.

So once again I ask, "How did this state of affairs come to be?" You know how there are legends about babies being trained to be Ninjas, and their parents dislocate their shoulders for them so they can do it more easily as adults, and get themselves into or out of tight spaces because they can contort themselves unnaturally? Well maybe there's a cult of some kind that drops babies on their heads or deprives them of oxygen so they can grow up to make rules about insurance coverage. Or come up with systems of psychiatric care that have everyone BUT psychiatrists seeing patients.

There's a Talmudic phrase that applies here. Roughly translated, it means,

The world has been given over into the hands of idiots.

What's In A Name?

Interesting article in Clinical Psychiatry News, Psychoactive Drug Nomenclature System Devised, by Mitchel Zoler.

Joseph Zohar, David J. Nutt, David J. Kupfer, Hans-Jurgen Moller, Shigeto Yamawakie, Michael Spedding, and Stephen M. Stahl have all been busy coming up with a new way to describe psychoactive medications. It's a 5 Axis system (I guess they were homesick for DSM-IV), and the plan is for it to be web-based, so it can be in a constant state of revision.

The idea behind it is that, according to the example in the article, you have a patient with an anxiety disorder, for whom you prescribe, say, celexa, which is an antidepressant. So the patient wonders why you're telling him he has one condition, and giving him a drug for another.

Here's my list of the axes-but you can view them in the article, in a nice table, complete with two examples:

Axis 1- Class and Relevant Mechanism
What neurotransmitters it affects, and what it does at the molecular level.

Axis 2- Family
This seems to overlap with Axis 1.

Axis 3- Neurobiologic Activity
Includes neurotransmitter effects, and broader physiologic effects.

Axis 4- Efficacy and Major Side Effects
What conditions it's good for, and what else it does on the experiential level.

Axis 5- Indications
Formal FDA approvals, I think.


The Pros:

The physicist, Richard Feynman, had an interesting father. He would say to young Feynman, "You see that bird over there? I can tell you its name, but first, I'll tell you what it does."

Names, categories, titles, they're all important, but they often don't give you that much information about whatever they're naming. "Sparrow" doesn't tell you anything. You need to connect that word with a certain type of bird.

So it's a good idea to describe drugs by what they are and what they purportedly do. You end up with a lot more information than you get from "SSRI" or "Prozac".

And on the flip side, "antidepressant" only tells you one thing that a particular drug does. If it does other things, you won't know it from that one word.

I quite like the idea of putting all the relevant information out there right from the start.

The Cons:

Who is this for? I can see where it would be useful for medical students studying for pharmacology exams. Or for psychiatrists, to tweak our memories, or help us clarify things to our patients, although personally I'd like an Axis 6 with Cyp450 enzyme data.

But what about non-psychiatrist prescribers. Could this be a sneaky way to promote off-label prescribing? If you look at the chart in the article, Axis 4 for amytriptyline is "anxiety;chronic pain", not "depression", which is listed in Axis 5 as "Major Depressive Disorder".

And does listing the known molecular mechanism of action, e.g "Increases synaptic 5-HT and norepinephrine" right next to the conditions the drug is used to treat, e.g. "Depression", sneakily imply that too little synaptic 5-HT causes depression, and more synaptic 5-HT is what "cures" depression? Because we just don't know if that's true.

Is this system for patients? Will it really be helpful, or more helpful than just telling these details to patients as part of discussions surrounding medication?

The question of who this system is for, as well as the plan to make the classification system web-based are particularly relevant, in light of the fact that I couldn't access the original article. Well, I could, for $35.95.

My feeling is that this idea is being presented as an ongoing collaborative model, but really, it's proprietary. And forgive me if I have concerns about where they're heading with it. This quote is from the Zoler article:

"This is the first step in a long process. We’re trying to wake up a 50-year-old nomenclature into a living document that will be used over the next decades and may someday merge with DSM [Diagnostic and Statistical Manual of Mental Disorders]," said Dr. Stephen M. Stahl, a panel member and psychiatrist affiliated with the University of California, San Diego.


What will it mean to "merge with DSM"? Will new diagnoses be created based on how medications are being prescribed? Or with what frequency they're being prescribed? After all, David Kupfer, one of the authors, was the chair of the DSM-5 task force.

And how will this affect getting FDA approval for medications? If a drug is being used off label at a high frequency, will this be a way to extend a patent? In other words, is noting the usage of a drug a way of establishing that said drug is effective for a different indication than the one it was originally approved for. 

My main concern stems from the memory of those little books I got from drug reps when I was a resident. Nice little pictures with colorful neurotransmitters happily making their way around a bunch of big receptors. All written by Stephen M. Stahl.

The final paragraph of the Zoler article:

Dr. Zohar said he has been an adviser or consultant to or received research support from eight drug companies. Dr. Nutt said he has been an adviser or consultant to eight drug companies. Dr. Stahl said he has been an adviser or consultant to more than 30 drug companies. Dr. Goodwin said he had been an adviser or consultant to 12 drug companies.


Bottom line: I think more information about medications is a good thing. But not if it's misleading. And not if there's an ulterior motive to presenting the information. Hopefully, this type of system can be used for the good of patients.

Who Needs Who

Check out this article in Psychiatric News, if you haven't already. 

Jeffrey Lieberman, president of the APA, asks us to be nice to poor, little Big Pharma. 

He notes past problems, "including high drug prices, aggressive marketing practices and direct-to-consumer advertising, efforts to buy influence with physicians, and, perhaps most egregiously, the suppression of data on drugs’ dangerous side effects."

He goes on to say:

But let’s face it, they need us and we need them. We must recognize the important, beneficial role that drug companies have long played in all areas of medicine. While not minimizing problems, we simultaneously must remember how products have improved the quality of health care and quality of life in our society, and their funding has helped to advance research, public outreach, and training.

He finishes up with:

We now are moving forward with careful vigilance in ways that recognize the value of industry relationships. Under the auspices of the American Psychiatric Foundation (APF), interactions with industry are helping to restore important relationships. ...I believe that the rules and models for informational, educational, and research engagement can and should be developed and applied in ways that allow for our optimal engagement with companies. Doing so would not only help us learn from the mistakes of the past; it would help us improve the future for our profession and our patients. 

I agree with the fact that we need them. Unless we want to put all our patients on Lithium and St. John's Wart, the meds have to come from someplace. And I don't fault Big Pharma for trying to make a buck or two billion.

But I also agree with the fact that they need us. No prescribers, no sales. So why do we have to be nice to them? And why does the president of the APA have to ask us to do so?

Sorry if I'm skeptical, but:

GlaxoSmithKline has admitted that some of its senior Chinese executives broke the law in a £320m cash and sexual favours bribery scandal.

And:

Big pharma mobilising patients in battle over drugs trials data.

The veracity of this last one is a little controversial, I suspect because Big Pharma intervened (See Eye For Pharma).

The idea is that if pharmaceutical companies make their data transparent for review and interpretation by the world at large, like in RIAT, science may be compromised, and private patient information may be revealed. 

I guess the world at large doesn't understand science as well as pharmaceutical companies do. And oh yeah, data for subjects in drug trials are anonymous.

(Please check out 1boringoldman.com for a more extensive discussion of this controversy)

So, again, why is the APA on a kick to endorse Big Pharma?

To quote Danaerys Targaryen, "I am only a young girl, and know little of such matters."

But I wonder what the APA gets out of the endorsement.

According to Gary Greenberg, regarding the APA's financial picture:

Income from the drug industry, which amounted to more than $19 million in 2006, had shrunk to $11 million by 2009, and was projected to fall even more. Membership was dropping, off by nearly 15% from its highs, and with it income from dues and attendance fees. Journal advertising was off by 50% from its 2006 high of $10 million.

I looked up the APA's 2012 Treasurer's Report, and found the following charts:

What's a picture worth, again?

These and These are the Words

I recently received this email from the NY State Psychiatric Association:

Just published field-trial research on DSM-5 shows that in routine clinical practice the diagnostic criteria are viewed as easy to understand and use by both clinicians and patients. This follows field trials in high-volume academic centers that found high reliability of the criteria in the revised manual. 

As part of the process that tested the more-dimensional approach that characterizes DSM-5, APA’s Division of Research conducted a series of field trials in settings of routine clinical practice. Researchers recruited a sample of 621 psychiatrists, clinical psychologists, social workers, counselors, and other licensed mental health professionals. Each participant was then asked to report on at least one randomly selected active patient. Data were provided on 1,269 patients, who also answered study questions. 

The clinicians reported that the revised criteria were generally easy to use and were useful in patient assessment, said principal investigator Eve Mościcki, Sc.D., M.P.H., and colleagues today in Psychiatric Services in Advance. “The clinicians put in a lot of effort collecting data on their patients,” she told Psychiatric News. Large majorities favored the overall feasibility of the DSM-5 approach, the clinical utility of the DSM-5 criteria, and the value of its cross-cutting measures. 

“These trials indicate that the DSM-5 approach works in a wide range of practice settings and a wide range of clinical settings,” said Mościcki. 

This sounds pretty good, doesn't it? But as it happens, I also recently finished reading Gary Greenberg's Book of Woe. And while I disagree with Mr. Greenberg on a number of points regarding the nature of psychiatry, I believe his data are accurate, especially those having to do with his own experience as a field trial participant.

In a press release on October 5, 2010, the APA announced that its field trials had started. There were to be two types of trials. One, across 11 academic centers, with two clinicians evaluating the same patient. Both evaluations would be vidoetaped and viewed by a third clinician, to establish reliability.

The second was the RCP, or Routine Clinical Practice trial, in which private clinicians would evaluate two patients, then re-evaluate a couple weeks later. The data would then be compared, and sent back to work groups who would tweak criteria and send them back to the clinicians for a second round of field trials.

But they hadn’t started as of October 5th, just a pilot study for medical center trials. The data from the pilot study needed to be analyzed, methodology modified, and clinicians trained before the field trials could begin in earnest. The academic center trials actually began between December 2010 and March 2011.

 At the end of 2011, two months before the data had to be in, 5000 clinicians had signed up for the RCP trial, 1000 had started the training, 195 had completed the training,  and 70 patients had been enrolled. The goal was 10,000 patients.

Mr. Greenberg's description of the field trial diagnostic interview demonstration at the APA meeting is one of the funniest things I've ever read. William Narrow, the psychiatrist in charge of research for the DSM-5, bungles his way through a clunky computerized interview, most of which is irrelevant to the fake patient's description of her problem, and this takes place after she has already entered her data extensively on her own section of the computerized interview.

There follows a debacle in which Dr. Narrow runs out of time, and then forgets to save his painfully acquired data. The conclusion, obvious from the initial description of extensive hoarding, is Hoarding Disorder. The audience is then asked their opinion on whether the criteria are an improvement over DSM-IV criteria, despite the fact that Hoarding Disorder doesn't exist in DSM-IV.

At the end, the question of reliability is raised by an audience member, Michael First, who was a prominent participant in the DSM-IV, and denied a position on DSM-5. Dr. First wanted to know how to tell if diagnostic discrepancies are the result of criteria or clinician style?

The answer provided had to do with Cohen's Kappa, a statistical measure of reliability introduced in the DSM-III. A Kappa of 0 indicates that agreement is due to chance, alone. A Kappa of 1 indicates that agreement is completely non-random. For the DSM-III, a Kappa of 0.40 was considered poor, and a Kappa of 0.80 was considered high. The same day as Dr. Narrow's demonstration, Helena Kraemer, chief statistician for the DSM-5, said that a Kappa of between 0.20 and 0.40 would be considered acceptable. In other words, the DSM-III reliability was inflated, so it was a good thing that the DSM-5 reliability would be much lower.

This is the APA's definition of, "...high reliability of the criteria in the revised manual."

I want to give you a taste of what Gary Greenberg's experience as a field trial participant was like. (This is from Kindle location 4635).

He sat with the patient, in front of his computer, for several hours, plowing through 49 pages of questions on mood disorders, 31 pages of questions on anxiety disorders, and 63 pages of questions on substance disorders.

He then had to rate the patient's responses on a 0-4 scale of severity:

Here I was given a choice. I could “proceed directly to rating” and pull a number out of the air, or I could get a “detailed description of levels.” I went for the details, which turned out to be extensive, 3 pages of descriptions about “identity” and “self-direction” and “empathy” and “intimacy”. Was she a Level 2-”Excessive dependence on others for identity definition, with compromised boundary delineation”? Or did she have the “weak sense of autonomy/agency" and "poor or rigid boundary definition" of a Level 3? Or was her experience of autonomy/agency “virtually absent” and her boundaries “confused or lacking,” which earned her a Level 4? Was her self-esteem “fragile” (Level 3) or merely “vulnerable” (2), or perhaps riddled with “significant distortions” and “confusions” (4)? Was her capacity for empathy “significantly compromised,” “significantly limited,” or “virtually absent”? Was her desire for connection with others "desperate,” “limited,” or “largely based on meeting self-regulatory needs?”

I had no idea. And even if I had, or if I knew how to get this confused and confusing woman to parse it for me, there still loomed thirty pages or so to get through, box after box to check about her self and interpersonal functioning, her separation insecurity and depressivity, her negative affectivity and disinhibition, the types and facets and domains of her traits, hundreds of boxes, or so it seemed, before I could make my final diagnosis, and, with the authority vested in me as a Collaborating Investigator of the American Psychiatric Association, determine which of the constructs that deserve neither denigration nor worship, that aren't real but still can be measured from zero to four, that need to be taken seriously enough to warrant payment and maybe a round of medication but not so seriously that anyone would accuse them of existing, which fictive placeholder would join her height and blood pressure and her childood illnesses and surgeries and all the other facts of her medical life. At which point I realized that no matter what diagnosis I settled on, I wouldn’t so much have tamed her rapids as funneled them into the diagnostic turbines, raw material for the APA’s profitable mills.

This is the APA's definition of, "...easy to understand and use by both clinicians and patients."

When I first got the email, I forwarded it to Mr. Greenberg, with a note stating that I thought he would appreciate it. He was kind enough to reply, and wrote, "If it weren't so sad, it would be hilarious." I have to agree.

Follow Up Poll

Back in April, I posted a survey about the DSM-5: whether people planned to purchase it, what people thought the problems with it would be.

Now I'm following up. I want to know if people have purchased it, and whether they feel it's been helpful.

Click HERE to participate. It's completely anonymous, and you don't need to have participated in the first poll to join in on this one.

This survey will close 07.27.13, 12am. Thank you in advance for participating.

DSM-5 in Action

Last week, I saw a new patient who was referred to me by her therapist for evaluation for med management, specifically, for depression.

The therapist wasn't certain the patient needed meds. And the patient wasn't sure she needed, or wanted meds.

She was suffering-that was the only certain thing.

I'm a decent psychopharmacologist, despite the fact that I mostly do therapy and analysis. The reason I'm good with meds is not because I'm an expert on the Cytochrome p450 system, or I'm the first shrink on the block to prescribe a brand new med. I believe it's because I listen to my patients, so important feelings/experiences/symptoms don't get overlooked, or boxed into neat little 15-minute med check categories that don't really fit.

So I listened to this patient, and while I was listening, I started thinking about everything I've learned regarding DSM-5. Like, maybe Major Depression, as defined by the DSM, doesn't really exist. (Note: I am NOT saying I don't believe depression exists. I'm just referring to the DSM definition of depression). And even if it does exist in DSM form, if I run through the checklist, and the patient meets five of the nine criteria, does that imply that she'll benefit from medication? And if she doesn't meet 5/9, does that mean she won't?

And what about the meds? What exactly am I treating? And how? A world-outlook? A traumatic childhood loss? If I can't be sure there's a disease process going on, and I can't be sure which aspect of the disease, if such it is, I'm treating, and no one even knows how the meds work, then why would I medicate?

I thought about how easy it would be to say to her, "You meet criteria for MDD, here's a pill, take it and you'll feel better." But I just couldn't bring myself to do that. I didn't believe it would help.

This is not the first patient I've sent home prescription-less. But it's the first time I've thought about it this way. In the past, I might've said to myself, the patient doesn't meet criteria, and therefore doesn't have the disorder in question, and consequently won't benefit from medication for this condition.

But now I'm reminded of the joke about the philosophy exam question, asking students to describe the physical characteristics of the chair at the front of the room. One student's response: What chair?

What disorder?

I came up with the following analogy: Suppose I decide that people who have more than 5 bad hair days per month carry a diagnosis of BHDD (Bad Hair Day Disorder). Am I describing an entity? Yes, people who have too many bad hair days. Does that make it a disorder, or disease?

I'm not sure the analogy is valid. At least some of the DSM diagnoses have a basis in clinical experience.

The truth is, and I realized this while I was writing, that I do find the DSM criteria for MDD useful, as a line of questioning.
This patient did not fit into any nice little DSM category. And I didn't try to make her fit. My thinking was, let's explore what she's been experiencing, using DSM criteria as a starting point. And that was useful.

I haven't purchased a copy of DSM-5. I don't want to. And I resent that, despite all the protests to the contrary, it remains the "bible" of psychiatry, and decisions are made based on its contents-reimbursement decisions, legal decisions.

But I do wish it could be what it professes to be: a guideline. Then it could sit on my book shelf with all the other books I use as references and guidelines, not with pride of place, and not with shame, either.

Learning from Diabetes

In a recent post, I wrote about how 126 became the cutoff for diabetes. It turns out that it was my fantasy about how 126 became the cutoff for diabetes. In response to the post, I got an email with a link to an article about the diagnosis of DM, which is, in the words of the person who sent it, "eerily like stuff going around re the DSM." I can't vouch for the accuracy of the article, but I'll summarize briefly.

A long time ago, back in the 70's, there were multiple standards for diagnosing diabetes. The reason for the multiple standards was that if you graph the sugars of a varied population at any given time, some will be elevated, but those don't necessarily correspond to the people who have diabetes.  Additionally, the graph never "jumps", so there's no clear cutoff point.

And at the time, there were limited treatments for diabetes, and essentially nothing to keep early type 2 from progressing. In addition, diabetes was quite stigmatized, and people with a diagnosis of DM could be refused health insurance, life insurance, employment, even a driver's license.

In 1978, the NIH convened a committee to establish a definition of diabetes, and the committee decided to place the cutoff higher than any standard had heretofore done, so that only people who unequivocally had DM would be given the diagnosis, and people who couldn't be helped anyway, such as early type 2 diabetics, would be spared the stigma, and its practical consequences.

And since a graph of a general population did not have a clear cut off point for DM, the committee looked at a subculture, the Pima Indians, whose graph did make a jump. Those Pima Indians whose Oral Glucose Tolerance Test was under 200 showed no symptoms of retinopathy, and those who did show signs of retinopathy had OGTT's over 240.

Then the committee decided to put the cutoff for fasting glucose at 140, higher than that of the typical diabetic Pima Indian, whose fasting glucose would hover around 120. Presumably this was done because at the time, OGTT was the test expected to be used to make a diagnosis, not fasting glucose.

In 1995, another committee was convened to re-examine the decision of the 1978 committee. This committee decided to use fasting glucose as the diagnostic test, presumably because it was cheaper, and it used a cutoff of 126, even though 121 seems to correspond with an OGTT of 200. They went with the highest number they could find in any study, specifically, a study of 13 Pacific populations.

There's more to the saga, but I'm gonna stop here with the diabetes. The take-home lesson for me is, Psychiatry is not such an outlier.

There are groups of people, including Gary Greenberg and his Book of Woe, who claim that Psychiatry is not as scientifically based as other medical specialties. Then there are other groups that claim it is scientific. Well, it appears to be at least as scientific as endocrinology.

A known disease entity, no one definitive diagnostic system, definition of disease determined by committee based on dubious scientific conclusions, the political stance not to further stigmatize people suffering from the disease, and a subsequent committee that examined the problems with the first committee's decisions, and then went on to make its own, new mistakes.

There is nothing new under the sun. A generation passes, and the world remains the same.

Read the article. It'll spook you. Even if it isn't accurate, it's exactly the same kind of rhetoric taking place now, about DSM-5.

Show Me The Science

I got this email yesterday:

NYSPA E-ALERT:  CONTACT YOUR LEGISLATOR TODAY REGARDING AUTISM BILL

All members are strongly encouraged to contact their local Assembly member or Senator today to oppose the passage of S.3044-A (Carlucci)/A.1663-A (Abinanti), a bill that would amend the Insurance Law and the Mental Hygiene Law to codify the DSM-IV definition of autism as the official definition of autism for the purposes of New York State law.  The proponents of the legislation seek to freeze the definition of autism because they are fearful that the new definitions in DSM-5 may diminish or eliminate eligibility for special education services in schools and/or health insurance coverage for community services.  This is simply not true and would be an improper intrusion of the Legislature into the realm of medical science.  Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine. 


I'm gonna ignore, for now, the topic of what role the government should play in medicine, and focus on that last sentence: Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine. 

Nu, so show me the science.

According to the DSM-5 description of the changes in criteria for Autism Spectrum Disorder:

The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings. 

There didn't seem to be any reference or link to the "real-life clinical settings", and it seems like, if a "real-life" study was done, it would have been published, or pending publication, at least cited. But I did check out the Huerta paper, published in October, 2012. Here's the method:

Three data sets included 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder). Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) and clinical observation instrument (Autism Diagnostic Observation Schedule) were matched to DSM-5 criteria and used to evaluate the sensitivity and specificity of the proposed DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.

I don't really understand what was done, and I'm not paying for the full article to figure it out.

These were the results:

Based on just parent data, the proposed DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses. Sensitivity remained high in specific subgroups, including girls and children under 4. The specificity of DSM-5 ASD was 0.53 overall, while the specificity of DSM-IV ranged from 0.24, for clinically diagnosed PDD not otherwise specified (PDD-NOS), to 0.53, for autistic disorder. When data were required from both parent and clinical observation, the specificity of the DSM-5 criteria increased to 0.63.

Okay, sensitivity 91% or less ("remained high"), specificity 0.53 to 0.63.  I'm a little confused. You have 100 patients who were diagnosed with DSM-4 PDD, and 91 of them were diagnosed with DSM-5 ASD. Normally, you would use a sensitivity of 91% to establish that the new standard you're proposing is adequate, since it's almost as good as the old standard. So the diagnostic standard you're comparing to is DSM-4, and you're saying that since  DSM-5 is almost as good as DSM-4, it's better than DSM-4.

What would make sense is if there were a third standard, the Autism Standard, which was the basis for diagnosing Autism. If DSM-4 had, say, 80% sensitivity, and DSM-5 had 91% sensitivity, compared with the Autism Standard, then you could conclude that DSM-5 was more sensitive than DSM-4.

Alternatively, if they're saying that DSM-5 only picked up 91% of cases because 9% of DSM-4 cases are inaccurately diagnosed, then you need to question the basis for DSM-4 criteria, so you can't use it as a standard to compare DSM-5 to.

To belabor the point: Suppose you're testing lexapro vs. prozac, and comparing both to nortriptyline. If lexapro helped 80% of patients who were helped by nortriptyline, and prozac helped 95% of patients helped by nortriptyline, you could reasonably conclude that prozac works better than lexapro. But if you compare lexapro directly with prozac, and you find that lexapro helps 91 of the 100 patients that were helped by prozac, you can't conclude that lexapro works better than prozac.
And if you then claim that lexapro does work better than prozac because prozac didn't really help all the 100 people it claims to have helped, then you have no idea what prozac does and doesn't do, so what does it mean to say lexapro works better?

See what I'm getting at?

You could argue that DSM-5 has better specificity than DSM-4, but the whole concern is that people who have a DSM-4 diagnosis of PDD won't all have a DSM-5 diagnosis of ASD, so some will lose needed services/treatment. So the concern is about missing a real case, not misdiagnosing someone who doesn't have PDD. In other words, specificity isn't the issue.

Moving right along.

I looked up some of those "other studies" that have been "inconsistent in their findings".

This study, by McPartland, et al, published in April, 2012, found these results:

When applying proposed DSM-5 diagnostic criteria for ASD, 60.6% (95% confidence interval: 57%-64%) of cases with a clinical diagnosis of an ASD met revised DSM-5 diagnostic criteria for ASD. Overall specificity was high, with 94.9% (95% confidence interval: 92%-97%) of individuals accurately excluded from the spectrum. Sensitivity varied by diagnostic subgroup (autistic disorder = 0.76; Asperger's disorder = 0.25; pervasive developmental disorder-not otherwise specified = 0.28) and cognitive ability (IQ < 70 = 0.70; IQ ≥ 70 = 0.46).

The study concludes that:

Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum. Revised criteria improve specificity but exclude a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder. A more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.


Another study found lower sensitivity and greater specificity, with sensitivity improving, although still less than DSM-4, if one DSM-5 criterion was relaxed.

Yet another study found lower sensitivity.

Let's see. We have "real-life" clinical settings without a linked study. We have one cited study demonstrating that some of the people with DSM-4 PDD diagnoses would lose those diagnoses under DSM-5, we have a statement that, "This is simply not true," and we have a sneaky little sentence dismissing, and not citing, those "other studies".

No, I don't think I will be contacting my local assembly member or senator.

Open Source-Please Comment

I have an idea, in very rudimentary form, and I'd like to get peoples' opinions on it.

But first, an amusing anecdote:

The attending who taught me ECT was a character. He'd been doing ECT forever, and his approach was quite old-school. When the patient started to seize, as noted by the twitching toe, he would determine the length of the seizure by counting, 1-Mississippi, 2-Mississippi, 3 Mississippi...
One time, I suggested we look at the clock, and he said, "No, no, this is better." 1-Mississippi was his definition of clinical rigor. Clearly, this was not science.

I read somewhere, some time ago, that the DSM (3?) committee voted on the criteria for MDD. "Those in favor of worthlessness/guilt? Approved! Those in favor of helplessness/hopelessness? Not approved!"

Clearly, this was not science.

But here's the interesting part. How was it determined that 126 was the cutoff for diabetes? I'm not going to look up the history, but I imagine it started with the idea that diabetes was a disease, whose symptoms included ketosis, polyuria, polyphagia, polydypsia, etc. And after seeing many patients with this condition, some clever person figured out that it had something to do with glucose. And later, they realized that if a patient's glucose level is too high, that patient has diabetes. And then "too high" needed to be defined. Presumably, they took a lot of patients who had known diabetes and compared them with normal controls by testing glucose levels. And eventually, they figured out that most patients with diabetes had glucose levels > 126, and most patients without diabetes had levels < 126.

That is science. And it involved a lot of data over a long period of time. Now, granted, they had a test they were looking at-plasma glucose concentration. And there are no convenient lab tests in psychiatry. But there is data.

Not the data you get from a drug-company-sponsored study, where fancy statisticians are hired to produce any desired reality (see, for example, this post). And not the data you get from a 20 person committee voting on a diagnosis.

But what if it was a 200 person committee? Or 2000? Or 20,000? Imagine 20,000 mental health practitioners chiming in on which symptoms they've seen the most. Or which meds they've found most effective. Or least. Or what type of therapy works best for what type of patient. One anecdote is meaningless. But 20,000 anecdotes? Not so meaningless.

I'm talking about the power of the internet. There was a time when the largest number of clinicians you could get in one place was at an APA meeting. Or a survey sent out by snail mail. Now, there's worldwide access at all times. Who needs the DSM when there's the possibility of open source psychiatric data and unlimited discussion?

Would this do anything to determine etiology? No. Not in and of itself, anyway. Would it be valid or accurate? Who knows? People are skeptical about Wikipedia, but is there any more cause for skepticism there than in an old-fashioned encyclopedia article written by one biased individual? Or one closeted committee?

Facebook changed the world by recognizing that a huge collection of connected individuals is a very powerful thing. Why can't we make that idea work to our patients' benefits?

Please comment on this post. I'd like to get a sense of what people imagine this could be like.

WHO-Hoo!

Here's some good news for anyone who doesn't want to buy, read,
or use the DSM-5.

The World Health Organizatio (WHO) provides free online ICD-10 access, and free online ICD-10 training. I worked through most of the training, and it's a bit dull, but pretty intuitive.

Fittingly, Mental and Behavioral Disorders are in chapter V.

Here's a peak at how depression is described, ICD-10 style:

Depressive episode

In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.

Incl.:

single episodes of:

• depressive reaction
• psychogenic depression
• reactive depression

Excl.:

adjustment disorder (F43.2)

recurrent depressive disorder (F33.-)

when associated with conduct disorders in F91.- (F92.0)

F32.0Mild depressive episode

Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1Moderate depressive episode

Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2Severe depressive episode without psychotic symptoms

An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present.

Agitated depression Major depression Vital depression

single episode without psychotic symptoms

Who-Hoo! No more Chinese menu!

ICD-10 codes are very different from ICD-9 codes, which are structured like DSM codes. Will insurance companies accept them? Looks like they will, starting October 1, 2014. Until then, ICD-9 will have to do.

Thanks, WHO.