My Third Letter to the APA Trustees

This letter was sent to the APA Trustees and to the DSM-5 Task Force on February 12, 2012, under the title, “Heads Up And Recommendations.”

DSM-5 press coverage has suddenly exploded-more than 100 stories from all around the world were published in just the last three weeks (see title and links below). The press is uniformly negative and extremely damaging to DSM-5, to APA, and to the credibility of psychiatry.

The APA responses have been few, unconvincing, and lacking in substance. Also troubling, 47 mental health organizations have expressed their opposition to DSM-5 by endorsing a petition requesting it to have a scientific review independent of APA. And many users are planning to boycott DSM-5 altogether by substituting ICD-10-CM (which will be freely available on the internet). It is fair to say that DSM-5 has become an object of general public and professional scorn.

What would Mel Sabshin be doing in this time of crisis? Of course, Mel never would have allowed APA to get into this mess-but once in any crisis he was an expert in damage control. Were he here today, Mel would certainly recommend that you immediately cut the DSM-5 losses to prevent its inflicting further damage on APA, on psychiatry, and most importantly on our patients.

Fortunately, there is an easy and obvious solution. Before more harm is done, simply reject the 5 most questionable DSM-5 proposals. This would mean: (1) keeping the bereavement exclusion in DSM-5 (turning grief into depression is by far the biggest object of public concern); (2) not reducing further the threshold for already swollen ADD; dropping both (3) ‘attenuated psychotic’ and (4) ‘disruptive mood dysregulation disorder’ (because they both risk furthering the already excessive use of off-label antipsychotics in kids and also lack sufficient research support); and (5) not allowing the expansion of pedophilia to include hebephilia (which would create a forensic nightmare).

The many positive results of finally dropping these worst and most dangerous of the DSM-5 suggestions would be immediate-the press quiets down; mental health professionals find DSM-5 less unpalatable; the risk is reduced of having the government investigate APA’s exclusive control of psychiatric diagnosis; the credibility of psychiatry is less tarnished; patients receive fewer inappropriate medications (and I get to drown my cursed blackberry in the ocean).

Other serious DSM-5 problems would certainly remain--highly questionable DSM-5 proposals, distressingly imprecise writing, and forensic risks. But these are less dangerous, less likely to completely discredit DSM-5, and can be addressed and corrected in a less fevered atmosphere. In contrast, the worst suggestions simply cannot be defended and need to be rejected quickly before DSM-5 is ruined by them.

As the responsible leaders of the APA, you cannot avoid your fiduciary responsibility to regain control of the staff and to rein in a runaway DSM-5 process. Continuing to do nothing means further loss of public and professional faith, dramatically reduced DSM-5 sales, APA budget shortfalls, declining membership, and potential loss of the DSM-5 franchise.

Time is running out and things are fast approaching a point of no return.

All of this was absolutely predictable and completely preventable 3 years ago. The longer you wait, the harder it will be to produce an acceptable DSM-5. Unless you act soon to make DSM-5 safe, the press, public, and professional reactions will undoubtedly just keep getting worse; there will be less time for correction, necessitating yet another DSM-5 publication delay; and the risks mount that the DSM’s will no longer be considered the standard for psychiatric diagnosis. You are reaching the point of “now or never.”

There followed a list of representative links to the 100 critical news stories. As expected there has been no public comment. Several internal sources indicate that APA intends to tough it out and stumble forward with all the risky proposals, the poor quality writing, the unacceptably low reliabilities, and the unmeetable publication date. DSM-5 appears to have past the point if no return and is flying blind.

Interested readers will find my warnings to the APA Trustees at the links that follow. My recommendations (with just a few exceptions) went unheeded. My predictions of impending DSM-5 disaster have sadly been more than realized.

June 2009
A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378

May 2010
DSM5-A Letter to the APA Board of Trustees
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1565491

June 2010
To the Membership of the APA
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1579837