The newest edition of psychiatry's "bible" of diagnosis, the DSM-5, made its long-awaited appearance on May 18 at the opening of the American Psychiatric Association’s (APA) national conference in San Francisco. This revision of the DSM-IV took the APA more than a decade to produce, and unprecedented criticism dogged it most of the way.
Because of the unique role the DSM-5 plays in the diagnosis of addiction—and, as a result, its influence on the allocation of billions of dollars for research, prevention, and treatment—The Fix has devoted extensive coverage in recent months to the controversies. Now, with the book launched and the dust settling, we turn our attention to two questions about short- and long-term consequences, and what people with substance use problems stand to gain or lose:
• Will treatment for addiction become more accessible for more people?
• Will research into addiction produce more effective diagnostics and drugs?
THE PROMISES AND PERILS FOR TREATMENT
The DSM-5 arrives in the midst of a historic overhaul of the nation's health care system under Obamacare (the Patient Protection and Affordable Care Act, or ACA). Together, the legislation and the diagnostics revision are likely to dramatically increase the number of Americans eligible for addiction treatment. But the noble goal of securing more care for substance users could have an unintended consequence, some experts warn: stretching an already-overwhelmed patchwork of services past their limits.
Once Obamacare kicks in, as many as five million people with substance use disorder will be newly eligible for insurance, according to an Associated Press analysis. The quandary: In most states, patients already fill treatment centers to the brim. The worst-hit states have only one rehab or hospital bed available for every 100 people in need of inpatient care. The new arrivals could double the existing wait lists.
The DSM-5 revisions were based on the same health care research that shaped Obamacare, and will work in tandem with the legislation to encourage early intervention in substance use disorders, Charles O'Brien, MD, Ph.D., head of the University of Pennsylvania's Center for Studies in Addiction and chair of the DSM-5's Substance-Related Disorders Work Group, told The Fix. By defining substance use disorder across a spectrum from “mild” to “moderate” to “severe,” the revision could add as many as 20 million more substance use diagnoses, Keith Humphreys, Ph.D., a Stanford psychology professor who served as a senior advisor on drug policy under Obama, toldThe New York Times.
That jump in diagnoses, paired with the ACA's expansion of coverage, will present a formidable challenge to already-shrinking addiction services. And since the majority of new diagnoses will likely be people in the initial stage of disease, critics fear that the most severe cases most in need of treatment will lose out. “Our scarce [addiction] resources are already distributed in an irrational manner,” Allen Frances, MD, who headed the DSM-IV revision, wrote in Bloomberg News. “We badly shortchange those with clear disorders while overtreating essentially normal people.”
That alarm misrepresents the large-scale, long-term changes likely to result from the one-two punch of expanded insurance and diagnosis, Humphreys told The Fix. "I think that's a misplaced concern and an old way of looking at things," he said, because it fails to consider how Obamacare will transform the provision of addiction treatment. To be blunt, insured patients can pay medical bills, so the new health care law will make addiction profitable. That will move the bulk of substance use care from the realm of government funding to that of private enterprise.
Hospitals and other private health centers will realize that the millions of newly insured addicts represent a source of customers, which could prompt their rapid expansion, Humphreys said. In another benefit, the provisions will likely shift services away from residential and stand-alone programs toward outpatient and integrated care systems.
But in the short term, Humphreys admits, there will be lag time before these “market adjustments” take effect. “While it's being figured out, some people will have a tougher time getting treatment,” he said.
The prospect of more accessible treatment for more people is based on two major changes in the ACA.
MEDICAID: Obamacare’s main strategy to cover most of the 30 million uninsured Americans is by an enormous expansion of this government program for the poor. (Health exchanges will allow uninsured people who do not qualify for Medicaid to shop for competing private insurers.) In the past, Medicaid covered only half of mental health and substance use services. New rules have extended that to two-thirds, and come January 2014, it will reach 100 percent.
PARITY: Under new "parity-plus" laws, health insurers will have to cover mental health and addiction care at the same rate as physical maladies.
But the Medicaid expansion may look better on paper than it works in reality. Why? Because the Supreme Court ruled last year that states have the right to restrict it. As a result, the effectiveness of the legislation will partly depend on whether or not states choose to implement the changes, said Susan Foster, MSW, vice president and director of policy research and analysis for the National Center on Addiction and Substance Abuse at Columbia University. Political agendas opposed to government spending appear to have shaped these choices, at least for the time being.
In additional changes, Obamacare relies heavily on cost-effectiveness—via prevention and early intervention—to bend the curve of runaway health care costs. And that's where the DSM-5 links arms most closely with the new Medicaid requirements, thanks to the manual's new “spectrum” approach to defining substance use disorder. The "mild" end of the DSM-5's substance-use spectrum will help health care providers identify patients at risk of, or in the first stages of, addictive behavior, O'Brien said. The DSM, in other words, will serve as a guide to help clinicians follow ACA mandates.
For example, a protocol called Screening, Brief Intervention, and Referral to Treatment (SBIRT) has shown success at halting substance use disorder before it gains much momentum. Yet insurers have refused to cover SBIRT, limiting the program's actual use. Obamacare aims to change that, mandating that Medicaid and state-exchange insurance plans cover SBIRT as a prevention benefit provided by primary-care physicians and in hospital emergency rooms.
One thing is clear: A major transformation in addiction diagnosis and treatment is underway, replacing a system that offers enormous room for improvement.
“I think the DSM-5 and Obamacare should work well together, synergistically," Humphreys said.
Yet this spectrum definition of addiction prompts dire predictions of critics like Frances, who say the change will increase diagnoses by, for example, turning "normal" binge drinking into a "substance use disorder" requiring treatment.
The research is mixed on whether or not that will happen. While an Australian study did, in fact, predict a shocking 62 percent increase in "alcohol use disorder" diagnoses under the DSM-5, two U.S. studies estimated much smaller increases (of 11 percent and five percent). “I doubt that the increase in diagnoses is going to be significant,” Foster told The Fix.
Patients identified on the "mild" end won't compete for services with full-blown addicts, anyway, Humphreys said. The two groups will get different kinds of care from different kinds of providers, with primary care physicians expected to handle most issues for mild abusers. "Early intervention is not about sending the guy who drinks two days a week to rehab,” Humphreys said.
Instead, clinicians can tailor treatment to each patient depending on the severity of his or her problem—rather than lumping all substance users together, Foster said. People who want to get control of an early-stage disorder may be “prescribed” a choice among, or combination of, 12 Steps, behavioral therapy, and anti-craving medication, for example. By contrast, those with a severe substance use disorder may require inpatient treatment at a hospital. "The diagnostic criteria help people understand that addiction is a disease," she said, "and that you have different levels of severity that call for different treatments."
Whether or not the ACA and DSM-5 work as planned to increase the quantity and quality of health care for people with addictions remains to be seen. There are countless potential hurdles. But one thing is clear: A major transformation in addiction diagnosis and treatment is underway, replacing a system that offers enormous room for improvement.
THE BRAIN SCIENTISTS VS. THE MIND DOCTORS
Right before its birth, the DSM-5 suffered perhaps its biggest rebuke. The world's largest psychiatric research organization, the National Institute of Mental Health (NIMH), rejected the very “validity” of the DSM’s approach to diagnosing mental illness.
The institute's director Thomas Insel, MD, went beyond the now-familiar complaints that the manual includes too many disorders, or the wrong ones, announcing that the traditional use of symptoms as a basis for diagnosis is hopelessly outdated—and that the NIMH would do its best to usher that system to the exits. “The NIMH will be re-orienting its research away from DSM categories ... and supporting ... emerging [scientific] research [such as] genetic, imaging, physiologic, and cognitive data,” Insel wrote.
The dominance of the DSM system has hampered that research, Insel said, preventing scientists from pinpointing the real causes of psychological suffering.
Holding the biggest purse in mental health research, the NIMH's decision will redirect the way money flows to addiction research—and, ultimately, how addicts are diagnosed and treated. The agency aims to replace symptom-based diagnoses with “biomarkers"—objective medical measures for psychiatric diagnosis that would be the mental health equivalent of blood pressure measures.
These markers, however, are currently little more than speculative. To discover them, the NIMH has launched its RDoC, or Research Domain Criteria project. While the NIMH won't be "abandoning" the DSM immediately, the agency's research money will increasingly go to studies that buck the DSM in favor of RDoC criteria, said Bruce Cuthbert, Ph.D., director of the NIMH's Division of Adult Translational Research and Treatment Development.
Though the National Institute for Drug Abuse (NIDA) and National Institute of Alcohol Abuse and Alcoholism (NIAAA) handle most addiction-specific research funding, they cooperate with the NIMH on many projects, said Wilson Compton, MD, director of NIDA's Division of Epidemiology, Services, and Prevention Research. The head of NIDA, Nora Volkow, MD, has led a veritable campaign to redefine substance use disorder as a brain disease best studied by the tools of neuroscience.
Coupled with Volkow’s priorities, the NIMH shift from soft to hard science will likely have a lasting effect on addiction research. "I wouldn't be surprised if these other organizations don't incorporate the new [RDoC] categories,” said Warren Bickel, MD, director of the Addiction Recovery Research Center at Virginia Tech Carilion Research Institute.
And that will change where the money for addiction research goes. Traditionally, to get funding, mental health studies have had to show their scientific validity by declaring which DSM-defined disorder they would investigate. Unfortunately, as Insel and many other scientists have said, mounting evidence suggests that DSM diagnoses simply don't match up with what's happening in patients' brains.
The system suffers from two main blind spots, according to critics. First, the underlying causes of mental suffering do not fit neatly into labels like "schizophrenia" or "substance abuse." Instead, these causes cut across many different DSM diagnoses. For example, malfunctions in what neurologists call the reward-circuit—the brain system that makes food, sex, alcohol, etc., pleasurable—occur in multiple disorders, including depression and addiction. Second, because the DSM lists so many criteria within each disorder, two patients can have completely different symptoms and yet receive the same diagnosis—as long as they meet the same number of criteria.
Addiction research is currently focused intensely on the brain's pleasure pathway and the brain chemical dopamine, asking if it is the true seat of addiction disorders. But scientists admit that given the brain's intricate complexity, the more they learn, the less they know. As the long as such biological causes of addiction remain a mystery, however, identifying precise targets and developing effective drugs are stymied.
RDoC-guided investigations won't produce results that affect diagnosis for years. That means the DSM remains the best available choice for clinicians who need to diagnose real problems in real patients, Cuthbert said.
Others, like Randy Brown, MD, director of the Center for Addictive Disorders at the University of Wisconsin-Madison Hospitals and Clinics, worry that research realignments like RDoC—together with President Obama’s “Brain Initiative,” a public-private research partnership—will steer money away from studies that could offer here-and-now benefits. "What's happening with the patient and the community has immense value," he said, “more so, sometimes, than a lot of the neurophysiological approaches."
Brown's concern about the NIMH's brain-centered approach echoes another recent, high-profile takedown of the DSM-5. The British Psychological Society (BPS) called last month for the abandonment of the DSM as an outdated collection of symptoms. But in their view, the problem stems from a focus on biology, including the neurological substrates that the NIMH wants to elevate. "The implicit theory [of the DSM] is one of biological reductionism," said Steven Coles, a clinical psychologist and co-author of the BPS statement. "We can do far more than we do to focus on psychological and social aspects" ranging from bereavement to unemployment."
Insel's announcement still signals a shift, however, and the DSM won't be around forever—on the research or diagnosis sides, Bickel said. "We're moving into a bold, new future where the influence of the DSM is on the wane."
For people battling addiction, that means a more scientific system in addiction care—someday. The future could see doctors analyzing MRI readings of your brain circuitry and tests of your genes to diagnose a substance use disorder. Only well-funded basic research will get us there, but until then, this much-maligned manual that is, after all, the repository of decades of psychiatric knowledge, will remain necessary.