Whether the new DSM-5 could make many more people addicts, and further burden cash-strapped state budgets … these are some of the questions being raised in articles and blogs, including a rather critical story appearing recently in the Sunday New York Times. The 5th edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders” is scheduled to be released in about a year. Addiction and related disorders is a new category, replacing substance abuse and dependence, and with generally broader guidelines, and a reduced number of criteria to meet standards for a diagnosis, the articles charge that tens of millions of people could be newly classified as having an addiction disorder – including those with the newly created category of behavioral addictions, which includes chronic gambling problems, and potentially others such as Internet, shopping and sex addictions.
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. The DSM, Diagnostic and Statistics Manual – the new version is due out sometime next year – was the subject of a big story in the New York Times this last Sunday critiquing it and a bunch of blog responses to that story. The article indicated that the new DSM-5 could result in millions more people, like on the order of 30 million more people being diagnosed as addicts, which will pose huge consequences for health insurers and taxpayers. And it also noted that ….the DSM reduces the number of symptoms required for a diagnosis. And then there’s the ongoing question of whether or not they are going to include behavioral addictions. They have, apparently, decided to include gambling as a chronic abuse issue, but other compulsive behaviors – shopping or food or sex are still being debated. Some clinical directors at treatment facilities and other places have responded by saying the story is overblown and overstates the case. So, Darryl, I just thought it would be interesting to talk about.
DARRYL: Well, one of the most fascinating things for me, Howard, is this has been talked about for at least 3 or 4 years, I mean, when it was announced that they were going to finally revise the DSM-IV-TR …it was well documented that they really were going to redo addiction and they were going to change the current diagnosis of addiction, which is substance use…it’s under a topic called “substance use disorder” in the manual. And they’re going to change that to “addictions and related disorders” and one of the controversial things was the proposed classification of drugs…drugs that affect the mind that can cause tissue dependence and cause withdrawal symptoms, but aren’t addictive in the classic sense – would be separating them from those associated with addiction and related disorders – and so they’re going to change the name from substance use disorders to addiction and related disorders so that they can really focus in on drugs that create tremendous emotional compulsion.
HOWARD: Did they change the level? Did they move it up on the scale?
DARRYL: No, it will be in about the same position, but what they announced and it was a big announcement – changing the classification from substance use disorder to addiction and related disorder, they also announced and this was 3 or 4 years ago the inclusion of gambling, because there was enough evidence to show the brain was affected in pathological gamblers in the same way cocaine or meth addicts were affected by those drugs. So that will be included and they were going to look at other behaviors before the May 2013 release date. It was also announced that they are presenting addiction as almost a throwback … almost a back to the future thing – when scientists and physicians first got into addictions, it was considered a spectrum disorder. They looked at a whole bunch of different levels of addiction and behaviors of addiction. You have “Jolmeck’s” disease, you have Benjamin Rush with his 8 different levels or 9 different levels. You had many, many people describe it as a spectrum disorder and DSM-5 announced 3 or 4 years ago that they’re at least going to look at moderate addiction or mild addiction, moderate addiction, severe addiction and maybe phenotype it even more to include description and symptoms that can allow, you know, a differentiation between the severity addiction. So this is something.
HOWARD: And that’s how you get these numbers, like 20 or 30 million more people.
DARRYL: Well, once they do that and start allowing for much broader definitions and more inclusive symptoms – some people will be considered to be moderately addicted – now its just – you’re an addict or you’re not an addict. That’s substance abuse disorder. But spectrum disorder, allows us to look at situations where people routinely drink more than they want to drink, or don’t have major life issues or major life problems, but are drinking more excessively than they should – as a mild addiction. Whereas now, that scenario wouldn’t meet criteria to be considered an addiction. But, my question is – why now? I guess it’s part of human nature for people to wait until the last moment before something’s going to come into play…then they’re excited and upset and they start criticizing or wanting to understand this and that.
HOWARD: Well it seems to happen all the time, people wait until the last minute.
DARRYL: Nothing that is being announced today is different than the announcements made 3 or 4 years ago but now it is a bee in people’s bonnet – where was all the discussion 4 or 5 years ago? One other thing that I’m really affected by and have questions about is who gets to work on the diagnostic criteria?
HOWARD: That is one of the things that came up in the story, it mentioned something like 165 people on the committee working on this revision and there was criticism that there are a lot of ties to Big Pharma.
DARRYL: There are people who are working on the new DSM-5 who are currently working for the big drug companies who make a lot of the new age addiction treatment medications and if these changes will increase potential users of these medications by 20 or 30 million – which is the projection – there is big money to be made.
HOWARD: …follow the money…
DARRYL: And that’s a horrible way to look at it but on the other side of the coin, currently the DSM-IV-TR is set up to identify addiction well after a person is deeply into their addiction – when it is more difficult to treat and has resulted in more consequences, and life problems. Expanding this diagnosis to allow for mild addiction, may serve to make people aware of their drinking patterns, their cocaine using patterns, their meth using patterns or whatever, which may lead to earlier interventions or earlier acceptance. It may lead to more careful attention to people’s drug use that could end up providing a great benefit, not only to them, but to our society and to treatment in general because they won’t be as needy as clients are now – who enter treatment in severe and late stage addiction.
HOWARD: Right. So, like with anything, if you treat something earlier, it usually has a better outcome.
DARRYL: Absolutely. It’s easier to treat. There’s less damage that has been done to a person’s life. When they do recover they haven’t lost as much and so they benefit more by early intervention and treatment. There are real positives for this new way of evaluation, but I can’t help but distrust the motives when a lot of the people sitting on the approval panel happen to work for drug companies who make addiction treatment drugs. Now to me, that’s a clear conflict of interest. Why is that allowed to happen? Why are people closely associated with the big drug companies who are making medications to treat addictions allowed to participate in defining what addiction is going to be?
HOWARD: And I don’t know how the committee was selected, but it’s an interesting question. That topic was brought up in the New York Times article by Dr. Frances, Dr. Alan Frances who was pretty much in charge of the DSM-IV – that question was asked – and it’s a good question. It’s a very good question.
DARRYL: Well it’s interesting he brought it up because he was in charge. Maybe the DSM-IV had a different panel approval.
HOWARD: Maybe it did.
DARRYL: The DSM-5 has a new panel approval process that allowed this potential conflict of interest.
HOWARD: That leads into another story that we came across – the implementation of the Mental Health Parody Act. The government has been seeking support and comments from people about whether or not there has been any success or what their success has been in getting insurance providers, in particular, but also I think hospitals and treatment facilities to respond to this new law, which has been in effect for a couple of years.
DARRYL: Well, it’s been a frustrating thing for me for the last 5 years, Howard, and I’ve talked about it every chance I could because it was actually in October of 2008, unfortunately right in the midst of the economic downfall.
HOWARD: Yes – the beginning of the of the big depression of modern times.
DARRYL: It was during that time George W. Bush signed into law the Mental Health Parody and Addiction Equity act. Paul Wellstone and Pete Diminichi as well as many other senators and representatives worked on that for 12 years. The mental health parody act stated that mental illness was an actual biological condition and people with schizophrenia or bipolar disease or depression, could not be discriminated against by society or by insurance companies or by states or anything else. And it took them 12 years to say, “wait a minute here! Addiction is more prevalent or just as prevalent as those other medical illnesses – so why is it not included? They battled it out and finally got both sides of the aisle to agree, Congress signed the act in October of 2008. I was all excited. The field was all excited. Finally – recognition that addiction is a true disease and …we’re just stunned that it’s 5 years later and no state has implemented the act. States like Michigan, like California, states with a real understanding of how addiction impacts society haven’t implemented the act. Maybe they are so afraid of how this is going to impact their bottom line or how much they may bankrupt their state once more people take advantage of this act to access treatment – that’s a bigger tragedy. Only 1 out of 26 or at least 1 out of 10 people who need treatment for addiction are able to access treatment and only 2 out of 10 who desperately want treatment are able to access treatment. So, we need to implement this act and bring it into play. I just heard the head of California’s substance abuse program, Michael Cunningham, make a commitment in Palm Springs. He says California will enact the parody act in 2013 and there is lobbying in Rhode Island Minnesota to enact this in their states, so maybe we finally have movement, but this is has been one of the most frustrating things I’ve ever seen in my life where both sides of the aisle agree to do something – pure science validates the action and yet, no state moves to implement the addiction equity act.
HOWARD: Well, that’s why we have state’s rights and that’s why we have federal government, so we can banter this back and forth and nothing really happens! I’m not cynical, by the way! That brings me back to a former question I was going to ask you about the DSM and that is, do you think in both of these instances, that the increase in our scientific understanding, especially our understanding of the brain and the technologies, especially imaging technologies that allowed us to understand it and view it better…do you think that’s been significant in both the changes in the DSM as well as in the creation of the Mental Health Parody Act.
DARRYL: Without a doubt, Howard. I mean imaging only came into big play during the 1990’s and during the 2000’s, led by Dr. Nora Volkow – her advocacy for exploring addiction through research and through empirical science and all of the other neuroscience departments around the United States who conducted research. The advancement in brain imagery showed major differences in the brain’s anatomy, less so, I think in the anatomy, more so in the activity….
HOWARD: Functionality…
DARRYL: Activity, the functionality and the communication between brain cells in addicts that normies don’t have. It affects only a certain subset of the US population, but it’s biological, it’s neurochemical, neuro-cellular and neuro-functional – anomalies I call them, or differences. DSM has added gambling because there were enough of these neuroimaging studies done on pathological gamblers that they could compare them with normies and they noted that those are the same parts of the brain, the same alteration and activities, the same communication, malformations and stuff like that that occur in methamphetamine and cocaine addiction. This prompted gambling to be moved out of impulse control disorders in the DSM and move pathological gambling into addictions and related disorders. I was really expecting sexual addiction, internet addiction, trichotillomania, which is pulling your hair out of your head, and conditions like that to be moved also. But after reading the articles out about the DSM 5, I think they’re going to copout because perhaps they don’t have the brain imaging research on these other behaviors. So, these other behavioral addictive disorders will be n.o.s. or not otherwise specified. That’s a catch-all term for classification. And the importance of this, unlike other diagnostic manuals in medicine, the DSM is the most respected. So much so that federal and state reimbursements for treatment of different mental disorders, including addiction, will be based upon what’s included in the DSM-5.
HOWARD: Including Medicare and Medicaid.
DARRYL: Exactly. So, for both federal and state it’s important, – even to the clinician and to treatment programs, because the information included is going to determine how much will be covered and/or whether providers will be able to charge for treating somebody.
HOWARD: Right, right. Well, like I said, we’ve talked about this before, but it came up prominently in the news, so I thought it was important to talk about it again.
DARRYL: The fervor that this has raised in just one week and we’re still maybe 11 months away from publication – all of a sudden everybody’s jumping out of their skin, jumping on one side or the other side, so I’m sure it’s going to come up again.
HOWARD: Hopping up and down on one foot and patting the top of their head.
DARRYL: I don’t know what influence it could have I don’t know how the committee makes their decision and what goes into that decision, whether or not they’re influenced by the passionate cries about how this is going to ruin us or help us or whatever…
HOWARD: Maybe we’ll hear from someone who’s on the committee or knows something.
DARRYL: That would be great!
HOWARD: It would be cool. That wraps our pod for today. Thanks for visiting and check back soon for the next in the series. Your comments, questions and suggestions are always welcome.