Two prominent University of Connecticut Health Center researchers are adding their voices to a chorus of other national experts who are questioning proposed changes regarding substance abuse guidelines in a manual used internationally in the diagnosis and treatment of mental illnesses.
Psychiatric epidemiologist Thomas F. Babor, head of the Department of Community Medicine and regional editor of the international journal Addiction, and Dr. Yifrah Kaminer, professor of psychiatry and pediatrics in the Department of Psychiatry and Alcohol Research Center, are concerned that pending changes to the definition of addiction in the Diagnostic and Statistical Manual (DSM) could represent a step backward in diagnosing and treating substance use disorders – and could have major economic and social consequences.
The manual, produced by the American Psychiatric Association (APA), has huge influence as a medical guidebook and legal reference. It is used by medical professionals to guide patient care, by insurers including Medicare to determine payment for treatment, by pharmaceutical companies to guide research, and by the legal system to determine mental competency in criminal trials.
The DSM is updated periodically by a committee of specialists in the field, based on the latest research and findings. The current version in use is the DSM-4. The DSM-5, which would contain the controversial updates, is scheduled for release in May 2013. The committee set a deadline of June 12 for feedback regarding the proposed changes to be submitted for consideration, and may or may not make revisions based on the objections heard.
Babor’s reservations about the proposed changes concern the broadening of language defining addiction and the lowering of the threshold of what counts as a substance use disorder. The revisions would expand the number of symptoms of addiction, reduce the number required for a diagnosis, and introduce a “behavioral addiction” category – all of which could lead to millions more people being categorized as addicts when they in fact are simply unhealthy users. This could put a strain on already-limited resources in schools, prisons, and hospitals, he says.
Kaminer, who has authored a number of books and publications on adolescent substance abuse, also criticizes the reclassification of certain terms related to substance use. In an article published recently in the American Journal on Addictions, Kaminer expressed concern about the DSM proposal to eliminate the diagnosis of substance abuse and classify all substance use disorders, even mild ones, as addictions.
“One of the problems with substance abuse is that people are ashamed and feel guilty,” he says. “In the case of adolescents, they and their parents and families carry it as a shameful issue, a guilt trip.” Classifying adolescent abusers as addicts can add to this embarrassment and could serve to deter them and families from seeking treatment.
Kaminer has worked extensively with adolescents and has developed rating scales used internationally, including the Teen Addiction Severity Index (T-ASI) and the Teen Treatment Services Review (T-TSR). He has directed numerous research studies involving this age group, including the current Adolescent Treatment of Marijuana (ATOM) Study, funded by the National Institute on Drug Abuse.
“With the population I work with, it takes a lot to get them to treatment,” he points out. “Adolescents will not seek help voluntarily; in most cases they are coerced by their parents, school, or the legal system. Now if you call them addicts, there is another turn-off and more shame and guilt, because society sees this problem as a personal weakness.”
The APA committee that suggested the revisions did so in the belief that the changes would lead to better diagnosis and economic savings in the long run, because identifying abusers sooner could lead to treatment before their abuse became severe and resulted in serious complications and the need for expensive health care services. But Babor questions whether the proposed guideline changes are clear enough to distinguish between individuals who need early intervention and those who need expensive substance abuse treatment.
“On the positive side, if this is used correctly and proves to be a way of early identification of a mild disorder, and if it leads to counseling by a doctor instead of formal treatment, there may not be cause for concern,” he says. “But in my opinion, the APA has gone to extremes in revising the criteria to cover so many disorders. A proliferation of diagnoses and the inclusion of people with mild disorders could compromise the ability of medical personnel to treat patients.”
Kaminer is concerned about the impact of the proposed DSM changes from two perspectives – classifying too many people as having a problem while deterring adolescents from seeking treatment. “There are not enough resources right now,” he says. “This country is collapsing under the burden of health care. Is it necessary to expand diagnosis to include mild cases and yet push away prospective clients by calling them addicts?”
The DSM is one of two manuals used as international references. The second is the International Classification of Diseases (ICD) produced by the World Health Organization, now in its 10th edition. Babor is involved in the work group that is revising the Substance Use Disorders section for the ICD-11, which is expected to be published in 2015.
Babor, whose research interests include screening, diagnosis, early intervention, and treatment evaluation, as well as cultural factors related to alcohol and drug problems, says the criteria for diagnosing substance abuse in the new ICD will differ from the DSM. “This may cause some confusion, because hospitals use the ICD for all conditions and there will be a discrepancy.”
The disparity between the two reference manuals points to the difficulty of defining behavioral disorders in general. “The American Psychiatric Association has made a good faith effort to develop useful criteria,” Babor says. “In some respects they lead the way in developing objective ways to come up with definitions of psychiatric disorders versus clinical judgment, which can be unreliable and arbitrary.”
Whether the objections of experts will be acted upon by the APA committee revising the DSM is yet to be determined. “I wouldn’t say that the proposed DSM revisions are an unmitigated disaster, but they could cause some difficulties,” Babor says.
“We could have lived with the DSM-4 without changing it,” Kaminer adds, “but if we are going to have a DSM-5, I believe it needs improvement.”