Mental Health Issues

DMS-5 Part II

~ Frank ~ Leave a comment

In my previous post on American psychiatry’s new and fifth edition of its “diagnostic manual” for mental conditions, I covered the history of the previous four editions of the “DSM” which stands for Diagnostic and Statistical Manual.

I will talk of two topics in this post; first as understandable explanation of the ‘sorting science’ that lies behind how psychiatric diagnostic categories are arrived at, and, second some of the misses and one correct addition in DSM-5.

The statistical science behind the DSM from its 3rd edition onward, is called “factor symptoms cluster analysis.” Quite a mouthful but simple concept once it is parsed and enumerated, element by element.

1. symptoms: these are the cardinal signs of an illness e.g., rash bumps and fever of chicken pox for instance. For sake of explanation I will grossly simplify all this and not get into such controversies as only a few symptoms in the world of medicine are truly unique and totally specific to an illness, which is called “pathogonomonic.”

2. all the symptoms that are clinically observed to appear in someone with the illness being considered are grouped together (clustered);

3. many cases and aggregated together, the more the better as in statistical sampling, it is a basic precept that the larger the sample size, i.e., the more people that are surveyed in a public opinion poll, the more accurate the groupings will be;

4. many clinicians, psychiatrists, are involved in pooling all these cases together as no one psychiatrist could have thousands of cases active of the same kind of symptom bearing patient illness;

5. a sorting process takes place in which it is determined, often in the early days before true computerized high speed sorting, counting and grouping could be performed, by manually grouping together cases that shared the same symptoms sets;

6. a name was discussed and commonly agreed to; its more specific subtypes were worked out with the addition of ‘qualifier’ description terms such as acute, subacute or chronic to give a simplest example (but one no longer used nowadays…);

7. confirmatory field trials were the performed utlizing the resulting description diagnostic criteria sets so generated and the members of the large working DSM edition task force would meet periodically, present cases they had found within their own worlds of practice and case by case debates would ensue whether the offered case “fit.”

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How Much Does It Cost To Take Psych Meds?

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For years as a psychiatrist I have observed the pharmaceutical companies charge huge amounts for every new psychiatric medication. This started in my view with the emergence of Prozac ( generic: fluoxetine) in the late 1980’s. Suddenly this drug cost several times what previous antidepressants had cost before Prozac. I felt later that part of what happened was the Big Pharma watched intently as the Reagan administration deregulated industries and let the “market forces” take over. They saw no enforcement or regulation of higher prices. They priced Prozac accordingly higher, much higher. But since Prozac was supposedly the best thing since toasters, and a ‘new’ class of antidepressant, many people were willing to pay the higher costs and the insurance companies largely followed suit and covered it.  All other classes of medications, antibiotics, blood pressure medications, etc., also took the initiative and priced their emerging drugs to market from then on and we had a spike in health costs as medications nationally became a higher cost for everyone including corporate entities since companies are now to be considered “citizens” due to the Supreme Court’s Citizen v. United States decision.

Perhaps a review of the drug pricing cycle is in order for the non medical professional reader. Drug companies have by law for decades, a 20 year exclusive right to a medication from discovery and patent filing, through research and development, drug trials and approval. This usually takes on average approximately 10 years. Then when a drug comes on the market, it is a “brand name” drug and its pharamceutical company can price it at whatever level they wish until that 20 year total is met. Then the medication goes “generic” and can be manufactured and sold by any other company after FDA approval in the generic pipeline which is much much shorter.

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Juxtaposition of the Opposites: Funny and Sad

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This column will be a little different from  my continuing overall mission to highlight issues of mental health reform in this country and in my home state of NC.

I had finally decided to take a digital camera with me a couple of weekends to a local mall and take a picture of one of the more public goofs I have seen in years. For the last three years whenever I drive by this mall and this particular strip of stores within it, my family and I always “hoot and holler” as is said in the South at this unbelievable contradiction in stores and signage.

Beside each other have long been a nationally famous weight loss chain store?/clinic and then next to it, the all too famous nationally revered doughnut store. And this is one of those doughnut stores that has the famous complete doughnut making machine and its automatic line of grease flat vats in which the doughnuts are fried and then the frosting unit that soaks them in that mouth watering glaze. Ever since I was a kid I have never lost my fascination with watching the doughnut machine crank out battalion after battalion of fresh shiny glazed doughnuts, an endless army of fat laden bombs.

But this past weekend as I drove over to the mall to hit the book store and other geeky stores, I saw that the two stores were no longer there juxtaposed right beside each other so I could take my picture and stick in a humorous blog post for the world to see this gastronomic health contradiction. One of the stores had closed. You guessed it, it was the weight loss store that bit the dust. I guess that says the national epidemic of obesity in this country is still going strong.

The other juxtaposition that was very sad and totally unfathomable was as follows. This past weekend on one of the cable television networks there was an incredibly well done documentary on Post Traumatic Stress Disorder (PTSD) in veterans returning from the Middle Eastern theaters of war. The interviews were humanely and considerately done and the vets and their families, ordinary people, were incredibly gracious to allow the all seeing, often unflattering television camera/camcorder eye into their lives. They were articulate to the point that I was moved to quiet tears and gut wrenching waves of anger at the still lagging lack of services they should be receiving, spasms of pain and sorrow for their suffering. My wife had the same reactions as we watched this program together since she is a retired social worker psychotherapist who practiced with me for many years until her M.S. and chronic fatigue forced to her stop working. We had read complimentary reviews of this documentary and had decided to schedule it into our evening time which rarely includes much television at all. (As the bumpers stickers might say: “We Still Read.”)

What was nothing short of appalling is that in the commercial breaks, over and over again, the network aired ads for joining the Armed Forces. I am not an anti-military type at all but the crass lack of consideration for the subjects of the documentary and families was shocking. Here was a superb documentary on their PTSD derived from their service to this country, cheapened by the presence of the ads for “joining up.” Whoever the top brass at the networks and advertising flacks that decided to stick these ads into this program were not thinking at all and had their minds elsewhere. What a colossal ‘politically incorrect’ and insulting boo-boo that must have struck many other viewers as puzzling, if not just plain incomprehensible. And I would not expect anyone to take credit for this scheduling display of idiocy. And I am sure the armed forces whose ads appeared in this context were not pleased either.

School Shootings, PTSD and Concentration Camp Survivor Syndrome

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In one of the venues in which I have practiced in the last 40 years of as a psychiatrist, I was asked to be a member two decades ago in a large city’s psychiatric/mental health trauma team by my partner at the time. He had served on the ‘team’ for some years and wished to give it up. He offered it to me and with my usual gung ho attitude of never turn a chance down to do something new and different, I assented to his offer and was accepted into the inter-agency body upon his recommendation. I underwent all sorts of training but mainly working with victims of mass hostage situations, shootings in public places, and mass industrial or urban accident scenes with the visual presence of much death and human destruction. To date myself, this work occurred over 20 years ago when the post office employees were cutting loose in fits of rage and shooting up large post offices, killing supervisors and fellow employees. Some of the situations involved angry employees who took customers hostage in numbers at their places of employment whether manufacturing plants or large retail stores in large malls. To be sure, all of these situations involved adult perpetrators not children. Our teams of mental health ‘first aid’ workers, or as they are now called, ‘first responders,’ primarily focused on separating victims and shocked witnesses away from the scenes of their spells of captivity,  of being hostages, when permitted by law enforcement and then debriefing them gently to start the painful process of ventilating the toxic and seemingly impossible feelings so that our follow up private office counselling could continue later.

I had a special interest in these issues that jumped up into my conscious realization of what my initially unaware or “unconscious” motives were as I underwent the initial training sessions. I was interested in the victims’ experiences of being traumatized since I had been an early to middle teenager. It was not that I had been abused myself. My motivations were  much more esoteric and farther removed from the growing wave of revenge motivated violence we see now in this country, now having filtered down to middle elementary school students who are often as angry as the begrudging adult mass shooters.

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Credible Spokesperson for Mental Health Reform

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This post will be a little different. I feel the personal and ethical obligation to recommend to readers a spokesperson, advocate and blogger for mental health reform who is one of the most creditable “experts” that i have run across in in now 14 years of first monitoring reform and restructuring of mental health care delivery systems in Michigan  (where I started my direction toward psychiatry in medical school), then Massachusetts and North Carolina where I have predominantly practiced.

This gentleman is one of the most articulate spokespersons and writers on this mental health reform monitoring scene. His name is D. J. Jaffe. On Pete Early’s blog I recently discovered one of Mr. Jaffe’s more recent essays written actually in the spring of this year, so I must confess I had “discovered” him somewhat ‘late.’ But am I glad I did. And I wish to do my part to try to make more well known his efforts by this brief mention, description and linking the reader to Mr. Jaffe’s work.

He heads up the advocacy group called “Mental Illness Policy Org” which is the ‘real deal,’ honest,  forthright and giving voice to what he sees as needed. There are many such sites and writers on all this mess called “mental health reform,” on the Net. But Mr. Jaffe is one of the most articulate and compelling writers I have encountered.

To quickly “meet” this man and his writings, please go to his article: “Against the Grain: D. J. Jaffe’s 8 Myths About Mental Illness,” at http://bit.ly/13M7NI6.

Read, savor, and give thought to his ideas backed up by good data where possible.

His article was hosted on Pete Early’s website, which is also worth following: http://www.peteearly.com, or the URL: http://bit.ly/13M9ipt.