Round up: ICD-11 PHC, ICD-11 Classification of Mood and Anxiety Disorders, Monograph: Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders, ASHA DSM-5 comments

August 1, 2012 by

Round up: ICD- 11 PHC; ICD-11 Classification of Mood and Anxiety Disorders; Monograph: Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders; ASHA DSM-5 comments

1] Paper: The primary health care version of ICD-11: the detection of common mental disorders in general medical settings By David P. Goldberg, James J. Prisciandaro, Paul Williams

2] The ICD-11 Classification of Mood and Anxiety Disorders: background and options (Guest Editors: Mario Maj, Geoffrey M. Reed), World Psychiatry, Volume 11, Supplement 1, June 2012

3] Monograph: Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11 By Shekhar Saxena, Patricia Esparza, Darrel A. Regier, Norman Sartorius

4] Submissions to DSM-5 public reviews for drafts one, two and three by The American Speech-Language-Hearing Association

Post #195 Shortlink: http://wp.me/pKrrB-2pa

This post relates to the World Health Organization’s ICD-11 and ICD-11 PHC (Primary Care version), both currently under development. It does not apply to the existing ICD-10, ICD-10 PHC or to the forthcoming US specific “clinical modification” of ICD-10, known as ICD-10-CM.

Note on ICD-10 PHC and ICD-11 PHC

ICD-10 PHC (sometimes written as ICD-10-PHC or ICD10-PHC or ICD-10 PC), is a simplified version of the WHO’s ICD-10 chapter for mental and behavioural disorders for use in general practice and primary health care settings. This system has rough but not exact equivalence to mental disorders in the core ICD-10 classification.

The ICD-10 PHC describes 25 disorders commonly managed within primary care as opposed to circa 450 classified within Chapter V of ICD-10.

A chart showing the grouping of categories adapted from the full ICD-10 version for the existing ICD-10 PHC categories can be found here.

The revision of ICD-10 PHC, ICD-11 PHC, is currently under development.

Professor, Sir David Goldberg, M.D., Emeritus Professor, Institute of Psychiatry, King’s College, London, is a member of the DSM-5 Mood Disorders Work Group. Prof Goldberg also chairs the Consultation Group for Classification in Primary Care that is making recommendations for the 28 mental and behavioural disorders proposed for inclusion in ICD-11 PHC.

The majority of patients with mental health problems are diagnosed and managed by general practitioners in primary care – not by psychiatrists and mental health specialists. ICD10-PHC is used in developed and developing countries in general medical settings and also used in the training of medical officers, nurses and multi purpose health workers.

Further information on ICD-10 PHC and the development of the mental health disorders section of ICD-11 PHC can be found in these two documents:

1] Goldberg, D. Guest editorial. A revised mental health classification for use in general medical settings: the ICD11–PHC 1. International Psychiatry, Page 1, February 2011.
http://www.rcpsych.ac.uk/pdf/IPv8n1.pdf

2] 21st Century Global Mental Health by Dr Eliot Sorel, Professor, George Washington University, Washington D.C.
Publication date: August, 2012: http://www.jblearning.com/catalog/9781449627874/
Page 51, Sample Chapter 2: http://samples.jbpub.com/9781449627874/Chapter2.pdf

ICD Revision publishes the names and bios of members of the ICD-11 Revision Steering Group, ICD-11 Topic Advisory Groups, and International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders.

But membership of the various sub working groups to the Topic Advisory Groups (TAGs), the names of external peer reviewers recruited by TAG Managing Editors for reviewing proposals and content and the membership of the advisory/consultation groups for the revision of the ICD Primary Care version have not been published by ICD-11 Revision.

The Abstract below lists members of the (WHO) Primary Care Consultation Group for the Revision of ICD-10 Mental and Behavioural Disorders.

1] Paper: The primary health care version of ICD-11: the detection of common mental disorders in general medical settings

http://www.ghpjournal.com/article/S0163-8343(12)00197-1/abstract

The primary health care version of ICD-11: the detection of common mental disorders in general medical settings

26 July 2012

David P. Goldberg, James J. Prisciandaro, Paul Williams

David P. Goldberg
Affiliations Primary Care Consultation Group, World Health Organization; and Institute of Psychiatry, KCL, London, UK

James J. Prisciandaro
Affiliations Department of Psychiatry, Medical University of South Carolina, Charleston SC, USA
Corresponding author.

Paul Williams
Affiliations Health Services & Population Research, Institute of Psychiatry, KCL, London, UK

Received 31 January 2012; accepted 19 June 2012. published online 26 July 2012.
Corrected Proof

Abstract

Background

The primary health care version of the ICD-11 is currently being revised.

Aim
To test two brief sets of symptoms for depression and anxiety in primary care settings, and validate them against diagnoses of major depression and current generalised anxiety made by the CIDI.

Method
The study took place in general medical or primary care clinics in 14 different countries, using the Composite International Diagnostic Interview adapted for primary care (CIDI-PC) in 5,438 patients. The latent structure of common symptoms was explored, and two symptom scales were derived from item response theory (IRT), these were then investigated against research diagnoses.

Results
Correlations between dimensions of anxious, depressive and somatic symptoms were found to be high. For major depression the 5 item depression scale has marked superiority over the usual 2 item scales used by both the ICD and DSM systems, and for anxiety there is some superiority. If the questions are used with patients that the clinician suspects may have a psychological disorder, the positive predictive value of the scale is between 78 and 90%.

Conclusion
The two scales allow clinicians to make diagnostic assessments of depression and anxiety with a high positive predictive value, provided they use them only when they suspect that a psychological disorder is present.

This article is partly based on the work of the World Health Organization (WHO) Primary Care Consultation Group for the Revision of ICD-10 Mental and Behavioural Disorders, of which the first author is Chair. Other members of the group include Michael Klinkman (GP, United States; Vice Chairman); Sally Chan (nurse, Singapore), Tony Dowell (GP, New Zealand) Sandra Fortes (psychiatrist, Brazil), Linda Gask (psychiatrist, UK), KS Jacob (psychiatrist, India), Tai-Pong Lam (GP, Hong Kong), Joseph Mbatia (psychiatrist, Tanzania), Fareed Minhas (psychiatrist, Pakistan), Marianne Rosendal (GP, Denmark), assisted by WHO Secretariat Geoffrey Reed and Shekhar Saxena. The views expressed in this article are those of the authors and, except as specifically noted, are not intended to represent the official policies and positions of the Primary Care Consultation Group or of the WHO.

Competing interests: David Goldberg is a consultant for Ultrasis and advises the World Health Organization and the American Psychiatric Association.

James Prisciandaro and Paul Williams have no competing interests

PII: S0163-8343(12)00197-1

doi:10.1016/j.genhosppsych.2012.06.006

+++
2] The ICD-11 Classification of Mood and Anxiety Disorders: background and options (Guest Editors: Mario Maj, Geoffrey M. Reed), World Psychiatry, Volume 11, Supplement 1, June 2012

The PDF of this publication is free.

Note regarding references within these commentaries to DSM-5 proposals: Some of these commentaries were written prior to the release of the third DSM-5 draft for public review, in May 2012, and quote draft proposals as they had stood for the second draft.

For example, the commentary Hypochondriasis in ICD-11 by D.J. Stein, on Page 100, sets out in narrative form the DSM-5 Somatic Symptom Disorder Work Group proposals and criteria for Complex Somatic Symptom Disorder as they had stood in May 2011 and are not the most recent iteration.

DSM-5 proposals have not been finalized. Proposals as they stood in May 2012 for the third and final public review may be subject to further change before DSM-5 is published in May 2013. Please refer to the DSM-5 Development website for the most recent proposals and criteria sets for the categories and proposed categories that are discussed in these commentaries.

http://www.wpanet.org/uploads/WPA-WHO_Collaborative_Activities/WP_ICD-11%20Supplement.pdf

July 2012

The ICD-11 Classification of Mood and Anxiety Disorders: background and options (Guest Editors: Mario Maj, Geoffrey M. Reed) World Psychiatry, Volume 11, Supplement 1, June 2012

Contents

The development of the ICD-11 classification of mood and anxiety disorders

M. Maj, G.M. Reed Page 3

How global epidemiological evidence can inform the revision of ICD-10 classification of depression and anxiety disorders

L.H. Andrade, Y.-P. Wang Page 6

Specifiers as aids to treatment selection and clinical management in the ICD classification of mood disorders

D.J. Miklowitz, M.B. First Page 11

Challenges in the implementation of diagnostic specifiers for mood disorders in ICD-11

M.B. First Page 17

Cultural issues in the classification and diagnosis of mood and anxiety disorders

S. Chakrabarti, C. Berlanga, F. Njenga Page 26

Bipolar disorders in ICD-11

S.M. Strakowski Page 31

Changes needed in the classification of depressive disorders: options for ICD-11

E. Paykel, L.H. Andrade, F. Njenga, M.R. Phillips Page 37

Differentiating depression from ordinary sadness: contextual, qualitative and pragmatic approaches

M. Maj Page 43

Severity of depressive disorders: considerations for ICD-11

J.L. Ayuso-Mateos, P. Lopez-García Page 48

Dysthymia and cyclothymia in ICD-11

M.R. Phillips Page 53

Psychotic and catatonic presentations in bipolar and depressive disorders

S. Chakrabarti Page 59

Mixed states and rapid cycling: conceptual issues and options for ICD-11

M. Maj Page 65

How should melancholia be incorporated in ICD-11?

D. Moussaoui, M. Agoub, A. Khoubila Page 69

Postpartum depression and premenstrual dysphoric disorder: options for ICD-11

M.L. Figueira, V. Videira Dias Page 73

Disruptive mood dysregulation with dysphoria disorder: a proposal for ICD-11

E. Leibenluft, R. Uher, M. Rutter Page 77

Generalized anxiety disorder in ICD-11

M.K. Shear Page 82

Agoraphobia and panic disorder: options for ICD-11

D.J. Stein Page 89

Specific and social phobias in ICD-11

P.M.G. Emmelkamp Page 94

Hypochondriasis in ICD-11

D.J. Stein Page 100

+++

3] Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11

Note: Substantial extracts from this DSM-5 and ICD-11 monograph can be previewed online on the Amazon site via the “LOOKINSIDE!” function. Greater access to preview content is available to Amazon account holders.  Extracts can also be previewed via Google:

Preview via Amazon “LOOKINSIDE!”:

http://www.amazon.com/Aspects-Diagnosis-Classification-Behavioral-Disorders/dp/0890423490#reader_0890423490

Preview via Google Books:

http://tinyurl.com/DSM5-ICD11-Monograph

Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for Dsm-5 and ICD-11

By Shekhar Saxena, Patricia Esparza, Darrel A. Regier, Norman Sartorius

(c) 2012

Paperback: 303 pages
Publisher: American Psychiatric Publishing; 1 edition (April 30, 2012)

Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11
[Paperback]

Shekhar Saxena (Author), Patricia Esparza (Author), Darrel A. Regier (Author), Benedetto Saraceno (Author), Norman Sartorius (Author)

Shekhar Saxena, M.D.,is Director of the Department of Mental Health and Substance Abuse at the World Health Organization in Geneva, Switzerland.

Patricia Esparza, Ph.D.,is Research Professor and clinical psychologist in the Department of Psychology and Counseling at Webster University in Geneva, Switzerland.

Darrel A. Regier, M.D., M.P.H.,is Director of the American Psychiatric Institute for Research and Education and Director of the Division of Research at the American Psychiatric Association in Arlington, Virginia; and Vice-Chair of the DSM-5 Task Force.

Benedetto Saraceno, M.D.,FRCPsych,is Professor of Psychiatry and Director of the World Health Organization Collaborating Center on Mental Health of the University of Geneva in Geneva, Switzerland.

Norman Sartorius, M.D., Ph.D.,is President of the Association for the Improvement of Mental Health Programs in Geneva, Switzerland.

Book Description
Publication Date: April 30, 2012 | ISBN-10: 0890423490 | ISBN-13:
978-0890423493 | Edition: 1

“Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for DSM-5 and ICD-11” provides a comprehensive summary of the current state of mental health classification in the United States and internationally, fostering a better understanding of primary research and clinical needs and facilitating the efforts of service planners, researchers and trainees to address current use of psychiatric diagnosis in the public health sector. The volume reflects the proceedings of a research planning conference convened by the APA and World Health Organization (WHO) that focused on public health aspects of the diagnosis and classification of mental disorders. Highly relevant to the ongoing development of DSM-5 and ICD-11, the book includes the background papers prepared and presented by the Conference Expert Groups. The resulting collection: – Discusses the current state of mental illness prevention efforts and the role of public health in supporting them–critical topics, given that development of effective strategies to reduce mental illness around the world depends on the accuracy with which risk and protective factors can be identified, defined, and understood. – Features international perspectives on public health implications of psychiatric diagnosis, classification, and service, providing viewpoints that are broad and more globally relevant. – Views mental health education, and awareness on a macro level, including its impact on social and economic policy, forensics and the legal system, and education. This approach facilitates the continued development of a research base in community health and promotes the establishment of programs for monitoring, treating, and preventing mental illness. – Addresses many fascinating and clinically relevant issues, such as those raised by the concept and the definition of mental disorders and how these impact psychiatric services and practice by individual providers.

This collection should prove useful to the advisory groups, task forces, and working groups for the revision of these two classifications, as well as for researchers in the area of diagnosis and classification, and more generally in public health.

+++
4] Submissions to DSM-5 public reviews for drafts one, two and three by The American Speech-Language-Hearing Association (ASHA)

The American Speech-Language-Hearing Association (ASHA) represents people with speech, language, and hearing disorders and advocates for services to help them communicate effectively.

ASHA submitted comments during all three DSM-5 draft comment periods:

ASHA submission April 2010 [PDF]; June 2011 [PDF]; June 2012 [PDF]

ASHA Letter sent June 2012 [PDF]

DSM-V Revisions To Move Forward (ASHA Leader article)

all documents available from this page:

http://www.asha.org/SLP/DSM-5/

+++

Key ICD-11 links and documents

ICD-11 Beta drafting platform  |  Publicly viewable version

WHO ICD Revision  |  Main WHO website: Revision Steering Group and Topic Advisory Groups
ICD-11 Revision site  |  Revision resources [Google site currently unavailable]
ICD-11 Revision site Documents Page  |  Key revision documents and meeting materials  [Google site currently unavailable]

ICD-11 Revision Information  |
ICD-11 Timeline  |

ICD Information Sheet  |

Revision News  |
Steering Group  |
Topic Advisory Groups  |

ICD-11 YouTube Channel  |  Video reports
ICD-11 on Facebook  |
ICD-11 on Twitter  |
ICD-11 Blog  |  Not updated since October 2009

ICD-11 YouTubes collated on Dx Revision Watch ICD-11 YouTubes  |

WHO Publications

ICD-10 Tabular List online Version: 2010  |  International Statistical Classification of Diseases and Related Health Problems 10th Revision Version: 2010, Tabular List of inclusions and Chapter List

ICD-10 Volume 2: Instruction Manual  |  Volume 2 online Version: 2010 PDF Download

ICD-10 for Mental and Behavioural Disorders Diagnostic Criteria for Research  |  PDF download
ICD-10 for Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines  |  PDF download

ICD-10 Volume 3: The Alphabetical Index  |  WHO does not make ICD-10 Volume 3: The Alphabetical Index available online

About the World Health Organization (WHO)

The WHO Family of International Classifications  

History of ICD

Filed under DSM revision process, iCAT, ICD revision process, ICD-10, ICD-11, ICD-11 Beta Draft, ICD-11 consultation, ICD-11 revision docs, WHO (World Health Organization) Tagged with , , , , , , , , , ,

Two commentaries from Allen Frances in response to APA field trial documents

January 19, 2012 by

Two commentaries from Allen Frances in response to APA field trial documents

Shortlink Post #130: http://wp.me/pKrrB-1GX

Allen Frances, MD, chaired the DSM-IV Task Force and a former chair of the Department of Psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

 

References and resources

DSM-5 document: Q & A on DSM-5 Prevalence and Reliability January 12, 2012

DSM-5 document: Reliability and Prevalence in the DSM-5 Field Trials January 12, 2012

based on the The American Journal of Psychiatry article DSM-5: How Reliable Is Reliable Enough? Helena Chmura Kraemer, Ph.D.; David J. Kupfer, M.D.; Diana E. Clarke, Ph.D.; William E. Narrow, M.D., M.P.H.; Darrel A. Regier, M.D., M.P.H. January 01, 2012, Vol. 169. No. 1

DSM-5 Field Trials page

Consumer-Friendly Frequently Asked Questions about DSM-5 Field Trials
Frequently Asked Questions about DSM-5 Field Trials in Large, Academic Settings
DSM-5 Field Trial Protocol for Large, Academic Settings
DSM-5 Field Trial Protocol for Routine Clinical Practice Settings
APA’s Request for Proposals for Potential Field Trial Sites
DSM-5 Field Trials in Routine Clinical Practice Settings
Supplemental Material for Clinician Application to Own Institutional Review Board (IRB)

Inside DSM-5 Field Trials, Flyer, American Psychiatric Association Practice Research Network, December 2011

Commentary: DSM-5 Disorganization, Disarray, and Delays, Dr Dayle Jones, PhD, January 3, 2012

 

Two commentaries from Allen Frances, MD

Two Fallacies Invalidate the DSM-5 Field Trials
APA telegraphs that DSM 5 will be unreliable.

Allen Frances, MD | January 16, 2012

The designer of the DSM-5 Field Trials has just written a telling commentary in the American Journal of Psychiatry. She makes two very basic errors that reveal the fundamental worthlessness of these field trials and their inability to provide any information that will be useful for DSM-5 decision making.

1) The commentary states: “A realistic goal is a kappa between 0.4 and 0.6, while a kappa between 0.2 and 0.4 would be acceptable.” This is simply incorrect and flies in the face of all traditional standards of what is considered ‘acceptable’ diagnostic agreement among clinicians. Clearly, the commentary is attempting to greatly lower our expectations about the levels of reliability that were achieved in the field trials – to soften us up to the likely bad news that the DSM-5 proposals are unreliable. Unable to clear the historic bar of reasonable reliability, it appears that DSM-5 is choosing to drastically lower that bar – what was previously seen as clearly unacceptable is now being accepted.

Kappa is a statistic that measures agreement among raters, corrected for chance agreement. Historically, kappas above 0.8 are considered good, above 0.6 fair, and under 0.6 poor. Before this AJP commentary, no one has ever felt comfortable endorsing kappas so low as 0.2-0.4. As a comparison, the personality section in DSM III was widely derided when its kappas were around 0.5. A kappa between 0.2-0.4 comes dangerously close to no agreement. ‘Accepting’ such low levels is a blatant fudge factor – lowering standards in this drastic way cheapens the currency of diagnosis and defeats the whole purpose of providing diagnostic criteria.

Why does this matter? Good reliability does not guarantee validity or utility – human beings often agree very well on things that are dead wrong. But poor reliability is a certain sign of very deep trouble. If mental health clinicians cannot agree on a diagnosis, it is essentially worthless. The low reliability of DSM-5 presaged in the AJP commentary confirms fears that its criteria sets are so ambiguously written and difficult to interpret that they will be a serious obstacle to clinical practice and research. We will be returning to the wild west of idiosyncratic diagnostic practice that was the bane of psychiatry before DSM III.

2) The commentary also states: “one contentious issue is whether it is important that the prevalence for diagnoses based on proposed criteria for DSM-5 match the prevalence for the corresponding DSM-IV diagnoses” …. “to require that the prevalence remain unchanged is to require that any existing difference between true and DSM-IV prevalence be reproduced in DSM-5. Any effort to improve the sensitivity of DSM-IV criteria will result in higher prevalence rates, and any effort to improve the specificity of DSM-IV criteria will result in lower prevalence rates. Thus, there are no specific expectations about the prevalence of disorders in DSM-5.”

This is also a fudge. For completely unexplained and puzzling reasons, the DSM-5 field trials failed to measure the impact of its proposals on rates of disorder. These quotes in the commentary are an attempt to justify this fatal flaw in design. The contention is that we have no way of knowing what true rates of a given diagnosis should be – so why bother to measure what will be the likely impact on rates of the DSM-5 proposals. If rates double under DSM-5, the assumption will be that it is picking up previous false negatives with no need to worry about the risks of creating an army of new false positives.

This is irresponsible for two reasons. First off, we are already suffering from serious diagnostic inflation. Rates of psychiatric disorder are already sky high (25% in the general population in any year; 50% lifetime) and we recently have experienced three runaway false epidemics of childhood disorders in the past 15 years. Second, drug company marketing has been so abusive as to warrant enormous fines and so successful as to result in widespread misuse of medication for very questionable indications. Recent CDC data suggest that the severely ill remain very undertreated, but that the mildly ill or not ill at all have become massively overtreated, especially by primary care physicians.

The DSM-5 proposals will uniformly increase rates, sometimes dramatically. Not to have measured by how much is unfathomable and irresponsible. The new diagnoses suggested for DSM-5 will (mis)label people at the very populous boundary with normality. Mixed anxiety depression and binge eating disorder will likely have astounding high rates between 5-10% – that’s tens of millions people now considered ‘normal’ suddenly converted into mentally ill by arbitrary DSM-5 fiat. Psychosis risk and disruptive mood disorder will be extremely common in the young; minor neurocognitive among the elderly. Legions of the recently bereaved will be misdiagnosed as clinically depressed; rates of generalized anxiety and addiction will mushroom; and ADD which has already almost tripled will find even more room at the top. The field trial developers seem either unaware or insensitive to the unacceptable risks involved in creating large numbers of false positive, pseudo-patients.

Indeed, quite contrary to the blithe assertions put forward in the commentary, we should have rigorous expectations about prevalence changes triggered by any DSM revision. Rates should not be wildly different for the same disorder UNLESS there is clear evidence of a serious false negative problem and firm protections against creating a massive false positive problem. And new disorders with high prevalences should not be included without substantial scientific evidence and convincing proof of accuracy, reliability, and safety. We have known since they were first posted that none of the DSM-5 proposals comes remotely close to meeting a minimal standard for accuracy and safety. And now, the AJP commentary seems to be softening us up for the bad news that their reliability is also lousy.

The workers on DSM-5 ignore the often dire implications of drastically raising the prevalence of an existing disorder or adding an untested new disorder with high prevalence – i.e., the misguided and potentially harmful treatment, the unnecessary stigma, and rising health care costs that also cause a misallocation of very scarce resources. Just two examples. Do we really want even more antipsychotic medications prescribed for children, the elderly, and returning war veterans when these are already being used so loosely and inappropriately? Isn’t the current legal and illegal overuse of stimulant medications already a big enough problem without introducing a drastically lowered set of criteria for diagnosing ADD? Sad to say, DSM-5 has failed to do an adequate risk/benefit analysis on any of its suggestions. Every one of its changes is designed to chase elusive false negatives; none protects the interests of mislabeled false positives.

Given our country’s current binge of loose diagnostic and medication practice (particularly by the primary care physicians who do most of the prescribing), DSM-5 should not be in the business of casually raising rates and offering inviting new targets for aggressive drug marketing. Instead, DSM-5 should be working in the opposite direction – taking steps to increase the precision and specificity of its diagnostic criteria. And the texts describing each disorder should contain a new section warning about the risks of overdiagnosis and ways of avoiding it. It is impossible to say what is the “right” prevalence of any disorder, but it is careless and reckless to so dramatically increase the prevalences of mental disorders without evidence of need or proof of safety.

The DSM-5 field trials have cost APA at least $3 million (perhaps a whole lot more). They started off on the wrong foot by asking the wrong question – focusing only on reliability and completely ignoring prevalence. The deadlines for starting the trials and for delivering results have been repeatedly postponed because of poor planning, an excessively cumbersome design, and disorganized implementation. The results will be arriving at the very last minute when decisions should have already be made. And now we get a broad hint that the reliabilities, when they are finally reported, will be disastrously low.

What should be done now as DSM-5 enters its depressing endgame? There really is no rational choice except to drop the many unsupportable DSM-5 proposals and to dramatically improve the imprecise writing that plagues most of the DSM-5 criteria sets.

DSM-5: How Reliable Is Reliable Enough?
DSM 5 is willing to except poor quality.

Allen Frances, MD | January 18, 2012

This is the title of a disturbing commentary written by the leaders of the DSM 5 Task Force and published in this month’s American Journal of Psychiatry. The contents suggest that we must lower our expectations and be satisfied with levels of unreliability in DSM 5 that historically have been clearly unacceptable. Two approaches are possible when the DSM 5 field trials reveal low reliability for a given suggestion: 1) admit that the suggestion was a bad idea or that it is written so ambiguously as to be unusable in clinical practice, research, and forensics; Or, 2) declare by arbitrary fiat that the low reliability is indeed now to be relabeled ‘acceptable’.

In the past, ‘acceptable’ meant kappas of 0.6 or above. When the personality disorders in DSM III came in at 0.54, they were roundly derided and given only a reluctant bye. For DSM 5, ‘acceptable’ reliability has been reduced to a startling 0.2-0.4. This barely exceeds the level of agreement you might expect to get by pure chance.

Previously in its development, DSM 5 has placed great store in its field trials. This quote is from the Chair of the DSM 5 Task Force: “There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made. Just because things have been proposed doesn’t necessarily mean they’ll end up in the DSM-5. If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward.”

And this quote is from a 2010 interview given to a science writer by the head of the DSM 5 Oversight Committee: “It’s going to be based on the work of the field trials – based on the assessment and analysis of them. I don’t think anyone is going to say we’ve got to go forward if we get crappy results.”

The DSM 5 tune has now changed dramatically. The commentary written for AJP by the leadership of DSM 5 Task Force appears to be suggesting that they will, in fact, “go forward,” and with sub par reliabilities of 0.2-0.4. Now consider that the original field trial plan was to have a second phase to permit fixing those diagnostic criteria that were found to have unacceptable reliability in the first phase. These would go back to the workgroups who could then rewrite the offending criteria and retest the new version in the second phase of the field trial. But poor planning and administrative foul-ups kept pushing back the field trials so that they are now at least 18 months late in completion. As time was running out, DSM 5 leadership quietly dropped the second phase of the field trials, removing any reference to it from the timeline posted on the DSM-5 website. Their Plan B substitute for adequate field testing appears in AJP- To wit: a drastic lowering of the bar for what is ‘acceptable’ reliability.

Can ‘accepting’ unacceptably poor agreement uphold the integrity of psychiatric diagnosis? Poor reliability degrades our ability to communicate with one another clinically, and prohibits meaningful research. ‘Accepting’ as reliable kappas of 0.2-0.4 is to go backwards more than thirty years to the days of DSM II. Before DSM III, Bob Spitzer and Mel Sabshin saw the need to develop a criterion based system that could achieve reasonable diagnostic agreement. This is the very minimum condition necessary for current clinical work and future progress in psychiatry.

Filed under Allen Frances, American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-V Tagged with , , , , , , , , ,

New DSM-5 Development docs: Reliability and Prevalence in the DSM-5 Field Trials

January 13, 2012 by

New DSM-5 Development documents: Reliability and Prevalence in the DSM-5 Field Trials

Post #128 Shortlink: http://wp.me/pKrrB-1F1

Two new documents have been posted on the American Psychiatric Association’s DSM-5 Development website.

(“What’s New” box on right of Home page)

 

                    Q & A on DSM-5 Prevalence and Reliability January 12, 2012

                    Reliability and Prevalence in the DSM-5 Field Trials January 12, 2012

Based on the The American Journal of Psychiatry article 

                    DSM-5: How Reliable Is Reliable Enough?

The American Journal of Psychiatry | January 01, 2012

Helena Chmura Kraemer, Ph.D.; David J. Kupfer, M.D.; Diana E. Clarke, Ph.D.; William E. Narrow, M.D., M.P.H.; Darrel A. Regier, M.D., M.P.H. January 01, 2012, Vol. 169. No. 1

 

Commentary from Allen Frances, MD, Psychiatric Times, January 09, 2012:

Two Fallacies Invalidate the DSM-5 Field Trials
By Allen Frances, MD | 09 January 2012

(Free registration required to view Psychiatric Times.)

“The designer of the DSM-5 Field Trials has just written a telling commentary in the American Journal of Psychiatry (AJP). She makes what I consider to be 2 basic errors that reveal the fundamental worthlessness of these Field Trials and their inability to provide any information that will be useful for DSM-5 decision making…”

Read on

Filed under Allen Frances, American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-V Tagged with , , , , , , , , ,

Newer posts →