I think this is a genuine concern to some degree, but it also seems important to decouple a diagnosis or treatment from the permanent condition or state of the individual. Perhaps with the new book there could be condition-based term limits on the diagnosed label. Treatments are supposed to shape the individual's development. Their diagnosis, it seems, would have to evolve as well.

Or, we could go the other way and make each name of the ~7 Billion people on Earth it's own individually specific disorder. E'errbody knows we all crazy anyway!

Erm...."autism specialists"...who do behavioral...as opposed to medication-based therapy...would be included under the umbrella term "behavioral health coverage."

And we COULD talk about autism, but the fundamental issue is the same...syndrome "disorders" in which the underlying biochemistry isn't understood.

I have no idea what your friend's coverage is like, but my current coverage is $20 copay, no lifetime maximum. This is in-network. I was simply pointing out the multiple insurance policies I'm familiar with to contrast it with the single example you provided.

And the coverage expansion has occurred recently...
which sort of undermines the position that dsm's role is to destigmatize mental health issues.

What is your thinking here? How would LSWs and CSWs have influenced the DSM to definitely prevent the large increase in autism diagnoses? (there are multiple questions here, really: why are you so sure? how many social workers would you need to get involved in order to have made the changes you would like? how much does changing the DSM change the rate of autism diagnosis?)

Patients of all sorts demand medications for all sorts of medical illnesses. Some doctors like being a pill mill, some hate arguing anymore, but some also do what's right and only prescribe if warranted.

What antidepressant is $200 per pill?
http://www.consumerreports.org/healt...nts_update.pdf
Pages 14-17, the highest cost I see is $540 for a month. I can't think of what it's missing that would cost $200/pill.

There is no way your insurance is going to let you get unlimited therapy with an autism diagnosis. I don't care what you think your policy is, but if you try to get the recommended 5-7 sessions a week for 2 years, insurance is eventually going to cut you off (usually sooner than later), our friend is an autism therapist and sees it first hand on a regular basis.

Edit; But the even bigger issue is that insurance is only going to be reimbursing the provider like $60 a session which probably isnt enough for a PhD to accept insurance so instead they go cash only and charge like $200.

Double Edit: All this is mostly a red herring, my whole point is that non-psychiatrist therapists (PhD/PsyD/LCSW/counselors/etc.) are the ones who are more likely to benefit financially from increased autism diagnosis when compared to psychiatrists. The overwhelmingly vast majority of autism therapy is done by non-MD's.

I suppose antidepressants were revealed to be somewhat (a lot of?) a farce in at least one recent meta-analysis, although for the individual patient it's nowhere near the scale of $20k/year. But there have to be way more people on antidepressants than those receiving therapy for PDDs. If you read the DSM IV criteria for major depression though, it's clear how many people could received the diagnoses. It's my personal belief that most clinically depressed people don't have "it," whatever "it" is (IANAD).

The thing I don't like about the DSM IV is the criteria used for diagnoses, such as the one linked above. They often read something like "has at least X of the following A (in J time period), and at least Y of the following B (in K time period)." I guess that's the best we can do now since there are no biological diagnostics available for these conditions, but it shows how incredibly difficult it is to identify the disorders when they are being treated as latent constructs. It's basically just empirically-based profile fitting, which is fine I guess, but it just shows how much we don't know about these things. Psychologists *should* be better equipped in construct and scale development than MDs, so I could see where their input could be helpful in creating the diagnostic tools.

Just curious, for MDD why do you think most people meeting those criteria, don't have "it" (I assume you mean whatever the actual real disease state is that we are attempting to classify as MDD).

Keeping in mind that "The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one" is part of the current criteria, although I think they may be controversially dropping that part from the next DSM.

We discussed it in the past, and I didn't agree very much with that article: http://forumserver.twoplustwo.com/47...l#post27169111
Certainly antidepressants aren't wonder drugs, but I would say they are effective, especially when the right one is given to the right person.


One of the criteria for all but 2 (I believe) diagnoses in the DSM is something like: "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning."

You're right, we don't know what depression really is, and some people without a real disease are going to get caught in by the criteria, but if someone shows up to your office meeting the above quoted criterion, I kinda feel they are deserving of medical/psychological help whether they have a disease or not.

Why is that? Tbh, I don't really know what is meant by "construct and scale development," so maybe this is actually obvious.

To be fair, I think PhD psychologists training probably better prepares them to construct diagnostic criteria just because they don't have to spend so much time on stuff like physiology/pharmacology so they are going to have a greater focus on things like statistics/psychometrics that probably lend themselves to being able to better consider the consequences of adding/removing certain criteria from a diagnosis. Also they have way more research experience so there is a good chance they know the literature better.

LSWs and CSWs are best described as "patient advocates."

Personal experience from a couple of decades ago was that they could find a diagnosis for every small complaint. This is as it should be, but they don't have the right training to do the work necessary.

Insurance is changing. The law forces the insurers to cover non-med therapy. Drastic improvement, since what we used to call "problems with everyday living" are better ameliorated by non-medical therapies.

I'm not sure what you meant by "practically demand" as if it were unexpected. Parents of annoying children want their children to be fixed and the drug companies have really cool commercials about how your child will be well-behaved and successful* if he takes some enhancement pills.

*two mutually exclusive things.

I'd agree. I stated from the start that people into research would be best for making the DSM. Though really psychologist or psychiatrist with a PhD would be good.

gansta, regarding your post in the other thread, that is more or less my understanding of the study. You make the point that the treatments were statistically significant but that the effects sizes (clinical significance) are small (which you claim their definition of small is somewhat arbitrary). IMO, effect size is what really matters here, not significance. I think they actually do report Cohen's d, which is a pretty ****ty effect size metric but is so standard that everyone reports it. And yeah, it's only an SSRI study and doesn't including other stuff like atypicals, but I don't think that really changes the point they are trying to make.

Just because these things are being treated as latent constructs, i.e. we say somebody is depressed, and that depression is a real thing, but we can't see it, feel it, touch, it, etc. You can't order a lab for it. So you have to develop some sort of instrument to say a person is depressed that differentiates them from people that are not. (Properly) developing instruments for construct measurement is nontrivial. Perhaps MDs are well-trained in this area, I dunno. My initial guess is that they are not (?), but psychologists typically have extensive training for this.

Edit: What surf said.

I say this as someone with bipolar disorder--it's just a theory based purely on my personal experiences. I always felt that, on the continuum

mildly depressed<-------------moderately depressed--------------->very depressed

there is some point you cross where they are just not the same thing. My unscientific, uninformed theory is that something fundamentally different is going on once you pass my imaginary inflection point. I suppose I see the Kirsch study as evidence supporting my theory, but it could just be confirmation bias. My overall point here is that we may be totally wrong on the conceptualization of depression.

Well, certainly if there isn't statistical significance, this conversation goes a much different way. So the real question now is if the drugs have a clinically significant effect, and maybe if certain drugs work on certain people but not others, then it would make them look not as good in the studies. The other problem I can't remember if I brought up or not is that some study participants probably didn't have 'it' as you say, but gave inflated symptoms just to be part of the study, and this group of people won't do better on SSRI vs placebo, so it brings down the measured clinical value of the drugs.

I don't think it's really clear either way at this point, but I certainly think there are reasons to believe in SSRIs over Kirsch's objections.

Ah, I understand now. You are absolutely right.

Aspirin for hangover (icd 305-ish), stitches for getting cut (icd 870 through 897 and 910-919), ice for a bad bruise (icd 920 through 924)), water for dehydration (icd 276.51). No disease, yet diagnosis.

Somehow people think this is different than part of what psychologists/psychiatrists should do.

The criteria for treatment should be (1) someone is suffering and (2) got some Tx available that will likely make them suffer less and (3) the suffering is greater than the costs (side effects, money, etc.) of the Tx, and (4a) either or we actually care enough to make it a societal utilitarian decision or (4b) they can afford treatment.

There are probably multiple causes causing very similar symptoms. Since we don't have sufficiently good tests to determine cause, we just try treatment 1, and if that doesn't work, try treatment 2, etc.

Obvoiusly, there is work to be done. No big deal in this particular part of medicine though. The same problem exists for chronic acne, chronic diarrhea and chronic constipation. You got to work with what tools you have today, while at the same time trying to invent new tools.

They don't typically have this. Some do.