On May 14, Dr. Keith Ablow, a Fox News contributor and practicing psychiatrist, posted comments on the Fox News website about the American Psychiatric Association and its current revision of the Diagnostic Statistical Manual. 

The DSM was created in 1952 to provide a complete and reliable source of diagnostic categories and descriptions of mental disorders. its formation was guided by two fundamental principles; that the diagnostic categories and criteria that define mental disorders, are supported by substantial scientific evidence, and that they are consistent with public health needs. the DSM is periodically revised to update diagnoses and their defining criteria as new knowledge is generated. the last revision to the DSM was in 1994.

In his article, Ablow made comments about the APA and DSM-V, which I believe are inaccurate and unsubstantiated by scientific evidence. Moreover, they are misleading to the public and potentially harmful in that by undermining the credibility of the psychiatric profession and its scientific underpinnings. they may even deter people in need from seeking treatment.

For this reason, I offer the following comments in response. I believe that I am qualified to do so as Professor and Chair of Psychiatry at Columbia University College of Physicians and Surgeons and the President Elect of the APA.

It is one thing to have a distressing and disabling psychiatric condition that affects one’s perception, cognition and emotions, and impairs quality of life, relationships and well-being.  but it is quite another level of tragedy when that condition goes undiagnosed, or when one is unable to get access to treatment because of stigma and shame or a lack of insurance coverage.  Relief from symptoms and recovery may be postponed or may never happen.  the consequences are not just inconvenience – as with any serious non-psychiatric medical condition, they are real, life-altering and potentially life-threatening.

For decades, the APA has worked diligently to provide definition in the environment of mental health through the development of the Diagnostic and Statistical Manual of Mental Disorders.  since DSM-III, each edition has provided evidence-based guidance in manual form for use by clinicians and researchers to diagnose and classify mental disorders so that patients in need can be effectively evaluated and gain access to treatments.

Since DSM-IV was released in 1994, there has been a wealth of new research and knowledge about the nature and frequency of mental disorders, how the brain functions and its neurobiology, and the lifelong influences of genes and environment on a person’s health and behavior.  Accordingly, the newest edition – DSM-V – will reflect that new body of knowledge.  And people who now suffer from a range of conditions will be the beneficiaries as they become increasingly likely to get an accurate diagnosis and access to treatment for it.

Many of the changes that are being proposed for this new edition were done to better characterize symptoms and behaviors of groups of people who are currently seeking clinical help but are less well-defined under the guidelines of the current DSM-IV edition.  the hope is that by more accurately defining disorders, diagnosis and clinical care will be improved and new research will be facilitated to help improve our understanding.  

The APA recognizes the importance not only of the document, but of the process for creating it and takes this responsibility with the utmost seriousness and as a sacred trust. Contrary to Ablow’s comments, the process for revision is not arbitrary and not politicized.  

For this revision, the APA recruited more than 160 of the top researchers and clinicians from around the world to be members of the DSM-V Task Force, Work Groups and Study Groups.  

These experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, and public health were rigorously vetted for any conflict of interest using guidelines derived from other academic professional organizations and from the federal government itself and have worked assiduously for over five years to scour the scientific literature and determine whether any changes to existing DSM-4 diagnoses and additions were warranted.  they participated on a strictly voluntary basis and come from several medical and health care disciplines including psychiatry, psychology, pediatrics, nursing and social work.

The definition of mental illnesses may at times be a matter of debate – and they should be.  but the importance of mental illness and the need to recognize and diagnose it cannot be understated.  Without them, diagnostic approaches could vary widely.  the treatment of conditions would be uneven.  Payment for services would be difficult, to say the least.

For too long in human history, persons with mental illness were feared, persecuted or ignored. Stigma of mental illness in our society was pervasive. 

However, through biomedical research and enhancement of public awareness we have made great strides in the U.S. to establish a strong scientific basis for our understanding of human behavior and brain disorders that affect mental functions and bring them out of the shadows so that people can recognize symptoms and seek treatment. 

That is why the APA has gone to great lengths, and taken great care, from every angle, to produce a document that incorporates new knowledge to develop the latest guidelines that will benefit practitioners and patients alike.

Dr. Jeffrey Lieberman is the chairman of Department of Psychiatry at Columbia University College of Physicians and Surgeons, and director at the New York State Psychiatric Institute.

Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to my Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Addington, J. Articles by Addington, D. Search for Related Content PubMed Citation Articles by Addington, J. Articles by Addington, D. am J Psychiatry 155:974-975, July 1998 Copyright 1998 American Psychiatric Association brief Report Smoking Cessation Treatment for Patients with Schizophrenia Jean Addington, Ph.D., Nady el-Guebaly, M.D., William Campbell, M.D., David C. Hodgins, Ph.D., and Donald Addington, M.D.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES OBJECTIVE: this study was an uncontrolled trial to assess the efficacy of a smoking cessation group program modified for individuals with schizophrenia. METHOD: Fifty outpatients with schizophrenia were divided into five groups who met separately for seven weekly sessions of a smoking cessation program. The subjects’ schizophrenic and extrapyramidal symptoms were assessed before the group sessions began and after they had been completed. Assessments of smoking were made at those times and at 3-month and 6-month follow-ups. RESULTS: Forty-two percent of the subjects had stopped smoking at the end of the group sessions; 16% remained abstinent at 3 months, and 12% at 6 months. These changes were statistically significant. there was no change in the positive or negative symptoms of schizophrenia. CONCLUSIONS: The results suggest that it is possible for individuals with schizophrenia to stop smoking. (Am J Psychiatry 1998; 155:974–976)

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES Individuals with schizophrenia smoke more than the general population and other psychiatric diagnostic groups (1, 2). in addition to the associated health hazards, the use of nicotine may interfere with the benefits of antipsychotic medication and increase side effects (2–4). Despite the increased focus on the health hazards of smoking, there are few reports of interventions for patients with schizophrenia (5, 6). A recent study (7) suggested that schizophrenic patients are interested in stopping smoking and are as motivated to do so as other people are. unfortunately, the symptoms and cognitive and social deficits associated with schizophrenia make participation in existing smoking cessation programs difficult. Thus, the purpose of this study was to evaluate the effectiveness of a smoking cessation program modified for persons with schizophrenia.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES The inclusion criteria for the study were that subjects be aged 18–65 years, be regular smokers, be stable outpatients, and meet the DSM-IV criteria for schizophrenia or schizoaffective disorder on the basis of a chart review. Persons who met the DSM-IV criteria for substance abuse or dependence (other than nicotine) were excluded. Sixty-five outpatients referred themselves to the study and completed the initial assessments. Fifteen had dropped out by the second group session.

Fifty subjects (29 male and 21 female) completed the group program and all four assessments. their mean age was 40 years (SD=8), they had a mean of 12 years (SD=2) of education, and their mean number of previous hospital admissions was eight (SD=9). The majority were single, lived alone, and received government financial support. Twenty-eight subjects were taking typical antipsychotics, and 22 were taking atypical antipsychotics. The mean dose in chlorpromazine equivalents was 425.50 mg/day (range=20–1350). this was a relatively naive group of quitters: 30 subjects had made no previous attempt to quit, 17 had used nicotine replacement, and three had attended a smoking cessation program.

Two raters were trained on all measures, and adequate reliability was maintained. The Positive and Negative Syndrome Scale (8) and the Simpson-Angus Rating Scale for extrapyramidal effects (9) were administered before and after the group program. Two other scales were used at all assessments: the Fagerstrom Test for Nicotine Dependence (10) and the Reasons for Quitting Scale (11), a 20-item self-report scale that assesses four dimensions of motivation to quit smoking, namely, health concerns, self-control, immediate reinforcement, and social influence. at each assessment subjects were classified as smoking or abstinent at that point. Reports of abstinence were validated biochemically by determination of urinary cotinine levels. Cotinine has a half-life of 14 days, has been used to validate self-reports of not having smoked in the past 7 days, and may be useful up to 3–4 weeks for validation (12).

The subjects were given a complete description of the study, after which written informed consent was obtained. Assessments occurred before the group sessions began, after the group sessions ended, and 3 and 6 months after the last group session. The subjects were divided into five separate groups (N=12 for two; N=10, N=9, and N=7 for the other three) for the seven weekly group sessions, which lasted for 75 minutes. All sessions were led by a psychiatric nurse experienced in working with schizophrenic patients and in groups. she became a certified facilitator for smoking cessation by participating in a 1.5-day training workshop sponsored by the Alberta Lung Association. The cotherapist was a graduate student. The group treatment was based on the seven-session group program “Freedom From Smoking” designed by the American Lung Association and was modified to meet the needs of individuals with schizophrenia. Adherence to the modified program was monitored throughout and ranged from 94% to 98% for each of the seven sessions.

The group program included positive reinforcement, learning and practicing alternative behaviors, and anxiety reduction strategies. there was a tolerance for positive symptoms, and social and financial limitations were considered. Teaching modifications were made to address neurocognitive deficits such as restricted information-processing capacity, memory and attentional difficulties, and poor executive functioning. A manual describing this group program in more detail is available from the first author.

Nicotine patches were offered to all subjects in conjunction with group attendance. Dosing began at 21 mg/day for 6 weeks and was then tapered to 14 mg/day and 7 mg/day for 2 weeks each.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES All reported results are for the 50 subjects who completed the group program. at the beginning of the program, the subjects were smoking an average of 28 cigarettes per day (SD=12) and had been smoking for an average of 23 years (SD=9). Nicotine dependence was high; the mean score was 6.39 (SD=2.09). Forty subjects initially used the nicotine patch. The average number of sessions attended was six; 50% of the subjects attended all seven sessions. According to the Reasons for Quitting Scale, the subjects were consistently more intrinsically than extrinsically motivated. their degree of motivation did not differ from that reported in the literature for nonpsychiatric subjects (7, 11). in order of importance, reasons for quitting were health concerns, self-control, immediate reinforcement, and social influence. changes over time were not significant.

Paired t tests revealed no changes in schizophrenic and extrapyramidal symptoms from before the group sessions to after (table 1). McNemar tests indicated that a significant number of the subjects (N=21) had quit smoking at the end of the group program. although this number decreased at both the 3-month and 6-month follow-ups, the numbers were still significantly different from the pregroup assessment (table 1). All but one of the subjects who quit had used the nicotine patch.

View this table:[in this window][in a new window]

we divided the subjects into four groups—those who never stopped smoking and those who were abstinent at the end of the group program, at 3-month follow-up, and at 6-month follow-up—and conducted analyses of variance to determine variables that might differentiate the groups. The results demonstrated no differences among any of the groups in medications, demographic characteristics, smoking variables, symptoms, or motivation. The one exception was attendance at the group sessions: the subjects who remained abstinent at the 3- and 6-month follow-ups attended all seven group sessions, those who had quit smoking at the end of the group program had attended 6.5 group sessions, and those who did not quit attended an average of 5.5 sessions (F=6.12, df=3,46, p=0.001).

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES Lack of a control group limits this study. however, the results were generally promising. These individuals had a long history of schizophrenia and had been heavy smokers for many years. All of the subjects expressed a strong desire to stop smoking, were intrinsically motivated, and generally showed good attendance. A substantial proportion of the subjects (42%) stopped smoking for at least 4 weeks. this number decreased to 16% at 3 months and to 12% at 6 months. although these percentages are less than the 20%–25% rates for quitting in the general population (13), they are comparable to the 15% rate at 6 months reported by Ziedonis et al. (6). These results suggest that it is possible for individuals with schizophrenia to stop smoking; the difficult part is maintaining abstinence. Quitting smoking should not be considered an impossible task for individuals suffering from schizophrenia. A group approach with nicotine replacement and with modifications of the group sessions could be effective.

Presented at the 150th annual meeting of the American Psychiatric Association, San Diego, may 17–22, 1997. Received June 20, 1997; revisions received Oct. 10, 1997, and Jan. 20, 1998; accepted Jan. 30, 1998. From the Department of Psychiatry, University of Calgary. Address reprint requests to Dr. Jean Addington, Department of Psychiatry, Foothills Hospital, 1403 29th St., N.W., Calgary, Alta., Canada T2N 2T9; jmadding{at}acs.ucalgary.ca (e-mail). Supported by a grant from the National Health, Research and Development Program of Canada.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES

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