NY TIMES
WASHINGTON — In what could prove to be one of their most far-reaching
decisions, psychiatrists and other specialists who are rewriting the
manual that serves as the nation’s arbiter of mental illness have agreed
to revise the definition of addiction, which could result in millions
more people being diagnosed as addicts and pose huge consequences for
health insurers and taxpayers.
The revision to the manual, known as the Diagnostic and Statistical
Manual of Mental Disorders, or D.S.M., would expand the list of
recognized symptoms for drug and alcohol addiction, while also reducing
the number of symptoms required for a diagnosis, according to proposed
changes posted on the Web site of the American Psychiatric Association,
which produces the book.
In addition, the manual for the first time would include gambling as an
addiction, and it might introduce a catchall category — “behavioral
addiction — not otherwise specified” — that some public health experts
warn would be too readily used by doctors, despite a dearth of research,
to diagnose addictions to shopping, sex, using the Internet or playing
video games.
Part medical guidebook, part legal reference, the manual has long been
embraced by government and industry. It dictates whether insurers,
including
Medicare and
Medicaid,
will pay for treatment, and whether schools will expand financing for
certain special-education services. Courts use it to assess whether a
criminal defendant is mentally impaired, and pharmaceutical companies
rely on it to guide their research.
The broader language involving addiction, which was debated this week at
the association’s annual conference, is intended to promote more
accurate diagnoses, earlier intervention and better outcomes, the
association said. “The biggest problem in all of psychiatry is untreated
illness, and that has huge social costs,” said Dr. James H. Scully Jr.,
chief executive of the group.
But the addiction revisions in the manual, scheduled for release in May
2013, have already provoked controversy similar to concerns previously
raised about proposals on autism, depression and other conditions.
Critics worry that changes to the definitions of these conditions would
also sharply alter the number of people with diagnoses.
While the association says that the addiction definition changes would
lead to health care savings in the long run, some economists say that 20
million substance abusers could be newly categorized as addicts,
costing hundreds of millions of dollars in additional expenses.
“The chances of getting a diagnosis are going to be much greater, and
this will artificially inflate the statistics considerably,” said Thomas
F. Babor, a psychiatric epidemiologist at the University of Connecticut
who is an editor of the international journal Addiction. Many of those
who get addiction diagnoses under the new guidelines would have only a
mild problem, he said, and scarce resources for drug treatment in
schools, prisons and health care settings would be misdirected.
“These sorts of diagnoses could be a real embarrassment,” Dr. Babor added.
The scientific review panel of the psychiatric association has demanded
more evidence to support the revisions on addiction, but several
researchers involved with the manual have said that the panel is not
likely to change its proposal significantly.
The controversies about the revisions have highlighted the outsize
influence of the manual, which brings in more than $5 million annually
to the association and is written by a group of 162 specialists in
relative secrecy. Besieged from all sides, the association has received
about 25,000 comments on the proposed changes from treatment centers,
hospital representatives, government agencies, advocates for patient
groups and researchers. The organization has declined to make these
comments public.
While other medical specialties rely on similar diagnostic manuals, none
have such influence. “The D.S.M. is distinct from all other diagnostic
manuals because it has an enormous, perhaps too large, impact on society
and millions of people’s lives,” said Dr. Allen J. Frances, a professor
of psychiatry and behavioral sciences at Duke, who oversaw the writing
of the current version of the manual and worked on previous editions.
“Unlike many other fields, psychiatric illnesses have no clear
biological gold standard for diagnosing them. They present in different
ways, and illnesses often overlap with each other.”
Dr. Frances has been one of the most outspoken critics of the new draft
version, saying that overly broad and vaguely worded definitions will
create more “false epidemics” and “medicalization of everyday behavior.”
Like some others, he has also questioned whether a private association,
whose members stand to gain from treating more patients, should be
writing the manual, rather than an independent group or a federal
agency.
Under the new criteria, people who often drink more than intended and
crave alcohol may be considered mild addicts. Under the old criteria,
more serious symptoms, like repeatedly missing work or school, being
arrested or driving under the influence, were required before a person
could receive a diagnosis as an alcohol abuser.