High on their list of concerns is the absence of transparency. Last July, Spitzer warned readers of Psychiatric News that the amount of secrecy cloaking the revisions was unprecedented and alarming. He quoted the contract that participants are required to sign, which reads, in part:
I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way ... any Confidential Information. I understand that "Confidential Information" includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group.
The APA alleges that the paragraph was not meant to block input from interested colleagues or output to the media (for which we are still waiting, by the way!). The president of the APA and the vice chair of the DSM-V task force bluntly dismissed other complaints about secrecy, insisting, against all contrary evidence, that its procedure is "a model of transparency and inclusion." The agreement was allegedly crafted to protect intellectual property. (The DSM is already copyrighted.) But the agreement also remains binding even afterDSM-V is published; to avoid breaking it, participants must keep their drafts, memos, and working papers to themselves. Apparently we're never to know exactly how or why bitterness, anger, and Internet addiction become mental disorders. Indeed, the contract appears to have been designed to make that omission a foregone conclusion—otherwise, why did the APA enforce it so rigidly at the start? When Spitzer requested the minutes of earlier discussions, he was told that if the APA made them available to him, it would need to share them with others.
After Frances made his objections public last month, he and Spitzer followed up by sending the APA an open letter: "Unless you quickly improve the internal APA DSM-V review process, there will inevitably be increasing criticism from the outside. Such public controversy will raise questions regarding the legitimacy of the APA's continued role in producing subsequent DSMs—a result we would all like to avoid."
Spitzer and Frances also strongly disagree with a proposal to include "subthreshold" and "premorbid" diagnoses in the new manual. Both terms give cover to the so-called "kindling" theory of mental illness in children and infants—some psychiatrists believe that it's possible to stamp out ailments before they burgeon into full-blown disorders. *
The kindling theory of infant mental disorders reminds us—as Darrel Regier (then the APA's deputy medical director) told the FDA's Psychopharmacologic Drugs Advisory Committee in October 2005—that the APA already considers 48 million Americans mentally ill. "Subthreshold" and "premorbid" diagnoses, warn Spitzer and Frances, "could add tens of millions of newly diagnosed 'patients' "—their quotation marks—to that roster, "the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment." Conceivably, we might by 2012 reach a point where the APA is defining more than half the country as mentally ill.
"In its effort to increase diagnostic sensitivity," Spitzer and Frances conclude, the DSM-V task force "has been insensitive to the great risks of false positives, of medicalizing normality, and of trivializing the whole concept of psychiatric diagnosis." These are remarkable accusations from two men who, between them, oversaw the formal approval of more than 150 mental disorders in two-dozen years.
In three years' time, will bitterness be seen as one of these disorders? Count me among the afflicted, if you must; some days that does seem possible, even likely. Given its track record and the grave doubts of two former editors of the DSM, should the APA really be given sole rights to decide something so consequential?
Correction, Aug. 3, 2009: This paragraph originally included two sentences about an article from the St. Petersburg Times on prescribing psychiatric drugs to very young children. The St. Petersburg Times article was about the sharp decline in such prescriptions in Florida in 2008, following new regulations, but the Slate piece reported only the much higher rates of prescriptions in 2007, misrepresenting the contents of the St. Petersburg Times' reporting. Those two sentences have been deleted. (Return to the corrected paragraph.)