by William Van Ornum, Ph.D. on
I wanted to continue the discussion points Evander Lomke recently raised (following an article published by University of Toronto) regarding what may be a plethora of new categories of pathology in the upcoming DSM V. It would appear that the psychiatric profession indeed is creating labels of “sickness” for many of the woes of everyday life. If, indeed, as T. S. Eliot said, “the human condition is always desperate”, do we need to come up with verbal categories that add more complexity and obfuscation to the already heavy human burden?
Perhaps the reason behind the DSM V is money. We are told in mystery novels to follow the money. Where is the money here? When the DSM I came out shortly after 1950, I suspect that most individual therapy was private pay. The DSM was a way for psychiatrists to distinguish between major conditions such as schizophrenia, depression, manic-depression (as bipolar disorder was called), phobias, and other major syndromes. Because mental-health professionals were paid privately, the notes written were meant to help jog the memory of the therapist, not document behaviors for insurance companies.
The big jump in diagnoses occurring with DSM III came at a time when the insurance companies were giving more oversight into mental-health reimbursement. There were abuses in the system caused by therapists, hospitals, and clinics. Some people used therapy, not to treat serious conditions, but as “purchase of friendship,” as one book of the time noted. Some hospitals offered cushy long-term treatment for months, even years. I heard of one patient who remained in the hospital for a year for mild depression while using the exercise facilities and writing a book.
Can we expect insurance companies (or indeed, the Federal Government) to dole out money for mental health uncritically? This is where a system like the DSM comes in. If treatment is to be made available for most people, then the ills that plague each and every one must be categorized. The problems of daily life may indeed become “pathologies”, but isn’t for many of these stresses that people seek treatment? In addition, a system like the DSM will strive to differentiate conditions that may need expensive long term-care, for conditions such as schizophrenia, bipolar disorder, and other conditions which incapacitate.
Another goal of the DSM V is to try to show the kind and length of treatment that works effectively for different mental health conditions: Empirically Supported Treatments (EST) are a new acronym that has been created, one that mirrors Diagnostically Related Groups (DRG) used to estimate or limit the care provided for medical conditions. Insurance companies want to know, “Why should we pay for something that doesn’t work?”
This situation puts those of us who advocate for better mental-health treatment in an awkward position: while asking that services be provided, are we taking into account financial necessities? Unfortunately, what is best in terms of care and treatment may conflict with existing financial realities.