Thursday, September 17, 2020
As Zachar et al note, what was originally envisioned was a shift to a "more scientific basis of psychiatric classification" to take account of the aetiology of mental disorders (see eg. previous post). The paper suggests that any hope for a shift from descriptive to aetiologically-based diagnostic criteria had been largely abandoned by the time the workgroups were finally formed in 2008, not least because the human genome project had not produced candidate genes for mental disorders and there was more questioning about what neuroimaging could achieve.
Darrel Regier reports that DSM-5 leaders were not willing to delay publication, even though the National Institute of Mental Health (NIMH) were about to launch its experimental approach that became the Research Domain Criteria (RDoC) (see previous post). This was because of "what amounted to a resurrection of those very aspirations [that had initially motivated DSM-5]". If this was really the case, then DSM-5 had some foresight, as speculation about neural circuits has gone overboard (see previous post) and Thomas Insel, the previous NIMH director, in my view led NIMH completely 'off beam' with RDoC and so-called precision medicine (see another previous post).
The paper suggests any decisions about changes were left to the workgroups. To give more direction to the process, BOT created an oversight committee in summer 2009. New guidelines accepted that “DSM-5 will not ‘in itself’ represent a paradigm shift, nor abandon the categorical system of classification, but will start a process that will lead to more useful ways of classifying and diagnosing disorders”. I’m not convinced it really did so, ending up merely with a tinkering with diagnostic criteria far short of the original misguided intentions. It would have been better if the time had been spent rethinking the basis of psychiatric classification (see eg. previous post).
Monday, September 14, 2020
Saturday, September 12, 2020
Friday, September 11, 2020
BJPsych Bulletin has an interview with Tom Burns, who I have mentioned previously (eg. see previous post). He talks about the OCTET study on community treatment orders (CTOs), which I have also discussed before (see post). Personally I think CTOs should never have been introduced (see eg. another previous post) and Tom now thinks he made a mistake in promoting them. It always strikes me as ironic that there used to be so much concern that a few detained patients were being kept on S17 leave too long, whereas essentially CTOs provide just such a 'long-leash' arrangement. As far as I can see, the introduction of CTOs has led to insufficient use of S17 trial leave. This almost certainly has reduced the opportunity for arranging informal community care without CTO.
Tom is also critical of DSM-5 (see eg. previous post). He's right to focus on descriptive psychopathology as a strength of psychiatry. He calls it 'diagnosis', which can be misleading because history and mental state examination actually lead to a formulation which includes differential (not necessarily a single and certain) diagnosis and aetiology. Diagnosis should not be overemphasised in psychiatric assessment (see eg. previous post).
Tom's also right about the fragmentation of services over the last 20 years. Hopefully the community mental health framework for adults and older adults will provide a basis for development but it does need leadership to implement it. Despite what Tom says, I haven't abandoned the use of the term 'patient', although also use the term 'service user', even 'survivor', certainly recognising the importance of mental health advocacy (does he?). Tom rightly expresses concern about clustering, which was supposed to support so-called payment by results, which seems to have been quietly dropped (see post on my personal blog). As he also indicates the overpreoccupation with risk has been damaging (see eg. my unpublished article and talk).
A younger version of Tom Burns sounded more optimistic in an e-interview. He even noted the "sense of excitement and 'importance' of psychiatry" created by RD Laing and how anti-psychiatry made the profession "glamorous, albeit controversial". He's still writing about the history of anti-psychiatry (see previous post and my letter).
(With thanks to Suman Fernando who alerted me to the recent interview)