Well, as I guess everybody knows by now, Dr. Insel has changed his mind. On April 29, he stated that the weakness of DSM “…is its lack of validity.” He went on to express the view that his agency, NIMH, (the US government’s mental health research arm) “…cannot succeed if we use DSM categories…” You can see his full statement here.
This statement was widely interpreted as a significant rift between NIMH and the APA. But apparently they’ve made up their differences and are pals again. On May 13, just two weeks after his divorce statement, Dr. Insel and Dr. Lieberman, APA president elect, have issued a joint statement in which they express the belief that the DSM “…represents the best information currently available for clinical diagnosis of mental disorders.” Patients, families and insurers, we are told, “…can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care.” It’s hard to believe that this is the same DSM that he earlier criticized as lacking validity!
A number of people have asked me what in the world is going on. So here’s my theory.
Dr. Insel is an honorable and learned man. After all, he was appointed by the government to a prestigious position, and as everybody knows, Washington only appoints honorable and learned men to prestigious positions. So Dr. Insel had been studying this matter for years – poring over learned journals, discussing with learned colleagues, etc., and finally came to the conclusion that DSM had no validity. He struggled with this because of the enormous implications, but finally honor prevailed, and he went public.
But a day or two later one of his faithful retainers came to him with some additional research findings that Dr. Insel had overlooked. He reviewed the new material and realized that he had made a terrible mistake. So he called Dr. Lieberman, and together they drafted the recantation. And as far as I am concerned, this raises him in my estimation. It takes a big man to admit he’s wrong. Well, he doesn’t actually admit he was wrong, but he comes as close to it as a man in a prestigious D.C. position can.
There are, of course, other theories. My friend Clive from Chicago, who is very knowledgeable about the ways of the world, expresses the belief that two heavy-set guys in big overcoats came into Dr. Insel’s office and said: “Do youse people want to work wid us or not?” Dr. Insel said “Uh?” Whereupon the heavy-set guys put a paper on his desk and told him that they would have his signature on the paper or his brains. This, for Dr. Insel was, if you’ll pardon the observation, a no-brainer.
My great Aunt Molly, who will be 104 next week, has been divorced four times. Her theory is that the marriage between APA and NIMH is in trouble. “You always see these little spat and make up patterns when things are starting to go south,” she observed. “Often there’s alcohol involved,” she added wisely.
I don’t associate much with psychiatrists, but there is one whom I encounter occasionally – Dr. I. Mapusher. I asked Dr. Mapusher what he thought of Dr. Insel’s recantation, and he confidently expressed the view that Dr. Insel has a brain illness. “Really?” I asked. “Oh, yes, definitely bipolar disorder. He made the first statement in a depressive phase, and the recantation when he was manic. Or perhaps the other way around. But definitely a brain illness. After all, according to the NIMH, the lifetime prevalence is 50%!”
So there it is. I still believe that Dr. Insel is an honorable and learned man who discovered his error and did the right thing.
But whatever the reason, the whole business looks more like political wrangling than professional/scientific debate.
Psychiatry has never been about science. It’s about marketing and spin. Dr. Insel opened a breach when he said – correctly – that the DSM categories are invalid. No one from the APA has honestly addressed this issue. Instead they’re churning out spin. The Insel-Lieberman statement is more of the same. For instance:
“By continuing to work together, our two organizations are committed to improving outcomes for people with some of the most disabling disorders in all of medicine.”
Now doesn’t that just make you feel good all over?