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"Proposed Amendments Of The DSM-5: The Exploitation Of Pharmaceutical Consumerism, Private Mental Health Professionals, And The State vs. The Individual Patient" by Gary Pustel


Proposed Amendments of the DSM-5: The Exploitation of Pharmaceutical Consumerism, Private Mental Health Professionals, and the State vs. The Individual Patient
by Gary Pustel

As used by both mental health practitioners and a variety of other professionals, the currently enacted edition of the Diagnostic and Statistical Manual for Mental Disorders ("DSM") IV-TR establishes distinctive criteria for the diagnosis of mental disorders. See Renee L. Binder & Dale E. McNiel, Some Issues in Psychiatry, Psychology, and the Law, 59 HASTINGS L.J. 1191, 1197-98 (2008). The American Psychiatric Association ("APA") has voiced its intent to appreciably modify the diagnoses for a variety of mental disorders for its new publication, the DSM-5. Id. However, the DSM-5 creates an entirely new calculus for the regulation and management of mental disorders as they current exist in our medical and legal frameworks. The DSM-5's proposed amendments have the potential to severely distort the utility and detection of mental health treatment, likely encouraging pharmaceutical companies and private mental health professionals to expand marketing appeal in an increasingly vulnerable "patient-directed" climate.

The APA's intent to amplify the range for clinical pathology substantially comports with the fiscal incentives of large pharmaceutical companies. See Pauline W. Chen, Have These Symptoms? Buy This Drug, N.Y. TIMES, Jan. 26, 2012, at A1. It is no surprise that brand-name advertising and marketing have historically influenced private medical practitioners in the physical and mental healthcare treatment of their patients. Id. However, in 1997, when the Food and Drug Administration eased the regulations for direct-to-consumer ("patient-directed") advertising in the United States, the evils of pharmaceutical consumerism exploded -- and patients suddenly became more vulnerable candidates for self-diagnosis, and ultimately, less reliable and trustworthy medicinal support. Id. Large pharmaceutical companies immediately advantaged themselves in the newfound absence of regulatory restraint, and drastically shifted their advertising objectives from private mental health professionals to patients. Id.

Most pervasively, "Disease mongering", the redefining of abnormality through means that help expand potential markets, became an integral method for big pharmaceutical companies to sell prescription medications. Id. "Disease mongering" is most prominent and effective through means of symptom checklists, which are conveniently placed for individual-patient leisure on Web sites, downloadable applications, and pamphlets in doctors' offices. Id. Symptom checklists have arguably become one of the most critical components of pharmaceutical marketing strategies in the era of patient-directed consumerism. Id. These checklists find such triumph because they present to prospective patients an over-inclusive range of self-diagnosable symptoms, thereby having the overwhelming consequence of directing and manipulating patient predilections.

As a primary example, the APA intends to expand the criteria for individuals who may fall under the umbrella of Major Depressive Disorder ("Depression"). Benedict Carey, Grief Could Join List of Disorders, N.Y TIMES, Jan. 24, 2012, at A1. In its present form in the DSM-IV, a Depression diagnosis requires the experiencing of at least five of nine specific symptoms, including sleeping problems and loss of concentration. Id. The current diagnosis explicitly excludes symptomatology of bereavement (the human grieving response to the loss of a loved one), which may easily be confused for a legitimate depression diagnosis. Id. However, the APA is considering the novel Bereavement Inclusion ("BI"), which would expectedly increase the number of individuals diagnosed with Depression. Id. The BI's next effect would astoundingly increase the number of individuals who could independently classify themselves under a Depression diagnosis under the guise of our heavily patient-directed mental healthcare system. As such, the BI appears to be suspiciously aligned with pharmaceutical companies' fiscal objectives. Many currently existing symptom-checklists strategically integrate symptoms that largely screen for anxiety-related disorders, yet ultimately lead an individual to identify with a Depression diagnosis, thus, the BI may only tend to increase the rate of self-misdiagnosis. See id. It would be difficult to postulate that the APA did not at all bear this in mind in proposing the BI, but if it somehow failed to do so, it was grossly irresponsible in neglecting to consider BI's net effect on prospective patients.

The BI will not merely endorse the evils of pharmaceutical consumerism; logically, it will similarly persuade Private Mental Health Professionals ("PMHP") to fiscally abuse the system. As a result of a patient-directed system, PMHP's will become more encouraged to evaluate patients less meticulously and thoughtfully, which would inevitably result in an enormity of inaccurate false-positive Depression diagnoses. This is not an issue that would realistically dissipate if the BI were to be excluded; the BI itself would merely help to financially benefit PMHP's at the expense of individuals' receipt of legitimate mental health treatment.

This is a particularly precarious result because of the growing elder population born in the "Baby-Boomer" generation, those individuals born between 1946 and 1964. See Beth A. Kapes, Depression and Baby Boomers -- How Having it All May Be Too Much, PSYCH CENTRAL, Aug. 30, 2006. Studies have indicated the increasing rate of Depression for adults born within the Baby-Boomer generation in comparison to previous generations, likely a result of lifestyles inundated with hard work and stress. Id. The first of the Baby-Boomers may soon experience bereavement at an exponentially increasing rate, thereby correlatively increasing the potential for manipulation by PHMP's. More particularly, the BI may likely enable PHMP's to over- and mis-diagnose a case of Depression in many individuals within the vulnerable elder population. From this perspective, the proposed BI modification for Depression appears wholly less patient-protective and utilitarian than its current form in the DSM-IV, and reasonably warrants extreme skepticism.

The APA also appears to indirectly promote the eradication of state funding for those who legitimately possess mental illness. As a primary example, the APA intends to drastically modify the diagnostic criteria for Autism. See, e.g., Amy Harmon, The Autism Wars, N.Y. TIMES, Apr. 7, 2012, at SR3. The APA plans to incorporate four distinct disorders (Autism, Asperger's, Childhood Disintegrative, and Pervasive Developmental Disorders) into one single broad-spectrum diagnosis, which will be introduced as Autism Spectrum Disorder ("ASD"). Id. This narrowing modification has vexing consequences; according to one estimate, the new ASD classification would reduce the combination of behavioral characteristics through which an ASD diagnosis can be qualified from 2,027 to 11. Id.

Consequently, studies have also demonstrated that the ASD as a contracted, surrogate classification would sharply reduce the number of individuals who had previously qualified for educational and behavioral services. See Benedict Carey, New Definition of Autism Will Exclude Many, Study Suggests, N.Y TIMES, Jan. 19, 2012, at A1. Thousands of individuals receive state-subsidy services to help treat and regulate the disorders' effects, including severe learning, cognitive, and social disabilities; thus, the new classification may likely exclude these very same people in desperate need of aid, those who may simply be of higher functioning capacity yet still significantly debilitated. Id. ASD would manage to exclude many who have a mild case of social dysfunction, including Aspberger's Syndrome, which has come to be understood as a "high-functioning" Autism. Id. A non-diagnosis overlooks the severity of the symptomatology of these disorders, because it equates these "mild" cases to sheer normality, which is misguided and potentially damaging. Further, future generations of individuals who would currently qualify under the DSM-IV criteria would lose the privilege of warranted state aid, and would be left without the potential to independently survive in society. Id.

Since a large portion of states' funds are devoted to aid individuals with autism-related disorders, one could question whether the APA is intending to shift fiscal responsibility away from the states, while providing more monetary leverage for PHMP's. Less, or absent, state involvement in the form of funding would necessarily equate to more individual, out-of-pocket funding. Consequently, the requisite affordability of care for early intervention and treatment of undiagnosed children could prove infeasible for many families. The exclusion of many may also impede the medical progress to discover the causes and potential cures for Autism and its related disorders. Unarguably, the APA's actual intent in this respect is not entirely clear. The impact that the new diagnostic classification may have on those currently in need, on the other hand, is transparently dangerous to the community of individuals with Autism.

Conclusively, the BI inclusion for Depression and ASD modification are two of several proposed modifications that appear superficially non-disruptive, but have dire implications. In the likely event these changes are effectuated in the DSM-5 in May 2013, the end result would find a hard-felt re-allocation of medical, educational, and monetary responsibility on to the individual, the result of pharmaceutical exploitation, PHMP's, and gradual eradication of state aid. A society in which individuals are essentially left responsible for the fate of their mental health status seems dystopian, excessively burdensome, and ultimately unworkable, but such would be the unfortunate manifestation of a capitalistic dream.

Gary V. Pustel is a 3L at St. John's University School of Law. He currently lives in Oceanside, NY. As a testament to his undergraduate degree in psychology, his primary areas of interest are mental health law, bioethics, criminal defense, and medical malpractice. He aspires to practice law in the near future either in New York, New Jersey, or Florida.

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This page contains a single entry from the blog posted on May 16, 2012 4:53 PM.

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