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2012
Controversies in Psychiatry and DSM-5: The Relevance for Social Controversies in Psychiatry and DSM-5: The Relevance for Social
Work (Occasional Essay) Work (Occasional Essay)
Jill Littrell
Georgia State University
, littrell@gsu.edu
Jeffrey R. Lacasse
jeffrey.lacasse@asu.edu
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Part of the Analytical, Diagnostic and Therapeutic Techniques and Equipment Commons, and the
Social Work Commons
Recommended Citation Recommended Citation
Littrell, J., & Lacasse, J. (2012). Controversies in psychiatry and DSM-5: the relevance for social work.
Families in Society, 93
(4), 265-270. DOI: 10.1606/1044-3894.4236
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Families in Society: The Journal of Contemporary Social Services
©2012 Alliance for Children and Families
ISSN: Print 1044-3894; Electronic 1945-1350
2012, 93(4), 265–269
DOI: 10.1606/1044-3894.4236
http://www.familiesinsociety.org/ShowAbstract.asp?docid=4236
Controversies in Psychiatry and DSm-5: The Relevance
for Social Work (Occasional Essay)
Jill Littrell & Jeffrey R. Lacasse
This essay addresses recent controversies surrounding the forthcoming fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5—the first major revision of the DSM since 1994), as well as questions regarding the safety
and efficacy of psychotropic medications discussed in the public domain. Mental health professionals across a wide range
of professions have signed a petition to the DSM-5 Task Force protesting changes in the new edition, and critiques of
psychiatric medications are increasingly disseminated in the media. These issues have particular relevance for children in
foster care, who receive diagnoses and medication at high rates. The general public is increasingly exposed to information
on these topics through the media; as advocates and clinicians, it is important that social work practitioners be informed
regarding these issues.
C
ontroversial issues in psychiatry are relevant to
social workers because they provide the major-
ity of mental health services in the United States
(Cohen, 2003; Mechanic, 2008). The controversy over
revisions in the upcoming fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) has
been widely discussed in newspapers and by the Public
Broadcasting System’s NewsHour. The efficacy of anti-
depressants has been questioned on 60 Minutes, when
Lesley Stahl (2012) interviewed Irving Kirsch. Recently,
a petition (Open letter to the DSM-5, 2011) launched by
the Society for Humanistic Psychology and several other
American Psychological Association (APA) divisions,
was posted on the Web (http://www.ipetitions.com/peti-
tion/dsm5). This essay will begin with some background
on what prompted the petition and why Allen Frances,
co-chair of the fourth edition of the DSM (DSM-IV), has
become a self-professed crusader. The relevance of the
controversies in psychiatry to indigent children and chil-
dren in foster care will be reviewed here as well. Concerns
about the problematic addition of new diagnoses and the
narrowing of diagnoses elsewhere for the DSM-5 will be
discussed. A brief overview of the controversy regarding
antidepressants will be presented. Finally, some thoughts
regarding how social work can respond will be proffered.
The Petition
e petition (Open letter to the DSM-5, 2011) asks the
DSM-5 Task Force to reconsider its intention to loosen and
expand the criteria for a variety of diagnoses. According to
Frances (2011c), this petition has been signed by more than
5,000 mental health professionals and 17 dierent mental
health professional organizations. Frances (2011b) earlier
had urged colleagues to sign the petition.
e petition to the committee developing the DSM-5
follows earlier attempts by Frances to prevent the Ameri-
can Psychiatric Association from “falling o a cli”
(Greenberg, 2010). Frances (2010), concerned about
the proliferation of new diagnostic labels, published an
article in the Los Angeles Times questioning whether
“normality is an endangered species.” Before this, Fran-
ces (2009) published an article in Psychiatric Times urg-
ing caution in the development of criteria for various
proposed disorders and decrying the unintended con-
sequences of the manner in which the DSM-IV criteria
were stated, which led to the epidemic rise in the diagno-
ses for attention-decit/hyperactivity disorder (ADHD),
autism spectrum disorders, and bipolar disorder. In an
interview, Frances explained his activism, “Kids getting
unneeded antipsychotics that would make them gain 12
pounds in 12 weeks hit me in the gut. It was uniquely my
job and my duty to protect them. If not me to correct it,
who? I was stuck without an excuse to convince myself”
(Greenberg, 2010).
e particular issue of children receiving antipsychotic
medications is connected to the rise in the diagnosis of
pediatric bipolar disorder. Although the diagnosis of pe-
diatric bipolar is not in the revised DSM-IV (DSM-IV-R),
no age restriction was placed on the adult diagnosis in the
DSM-IV-R. When Harvard University’s Joseph Bieder-
man and colleagues began publishing articles reporting
that children, many of whom had been previously labeled
as conduct disorder or ADHD, met criteria for bipolar
disorder, the diagnosis of pediatric bipolar took o (Lit-
trell & Lyons, 2010a). Whereas it had been assumed that
bipolar disorder never emerged until late adolescence or
adulthood, by 2004 it was the most frequent diagnosis for
children (Blader & Carlson, 2007). A similar increase in
bipolar spectrum diagnoses was witnessed for adults as
well, according to Moreno et al. (2007).
As more children and adults were labeled bipolar, the
use of atypical antipsychotics escalated. Domino and
Swartz (2008) documented the rise in the use of atypi-
cal antipsychotics for both children and adults. Most re-
cently, Comer, Mojtabai, and Olfson (2011) documented
FAMILIES IN SOCIETY | Volume 93, No. 4
266
an increase in the use of atypical antipsychotics for the
treatment of anxiety disorders. As the addictive liability
of tranquilizers has received attention, an atypical anti-
psychotic, Seroquel (quetiapine), is now being used for
insomnia (Sinaikin, 2010).
While Comer et al. (2011) documented the rise in the
use of atypical antipsychotics, others have documented
the deleterious impact of the atypicals. In February 2011,
Ho, Andreasen, Ziebell, Pierson, and Magnotta (2011)
published their ndings of brain volume reduction given
the use of antipsychotic medications (both older neuro-
leptics and the new atypicals). While the Ho et al. study
did not use random assignment to conditions, and thus
causality could not be inferred from their data, the re-
searchers cited animal work with the same ndings,
where random assignment was observed. Aer 27 months
of dosages in the therapeutic range for people, there was
an 11.8–15.2% reduction in the parietal lobe and a reduc-
tion in total weight of brain volume (Konopaske et al.,
2007, 2008). Brain tissue volume decrement is only the
latest recognition of the devastating impact of the atypi-
cal antipsychotics. Atypicals are associated with weight
gain that does not plateau, high levels of blood lipids, and
increased risk of diabetes (Goodwin & Jamison, 2007,
p. 846), as well as osteoporosis (Kawai & Rosen, 2010). Al-
though the atypicals were initially believed to be free of
movement disorder risks, the Clinical Antipsychotic Tri-
als of Intervention Eectiveness (CATIE) study, a large
government-funded study, revealed that the atypicals,
like older neuroleptics, can cause movement disorder
(Casey, 2006). Additionally, the Food and Drug Adminis-
tration (FDA) has issued a warning regarding Seroquel’s
capacity to induce cardiac arrhythmias and sudden death
(Wilson, 2011).
Relevance to the Child Welfare System
Children covered by Medicare and Medicaid are more
likely to receive prescriptions for antipsychotics than
privately insured children. High proportions of foster
children are being medicated with antipsychotics and
polypharmacy (dosReis, Yoon, Rubin, Riddle, Noll, &
Rothbard, 2011; Littrell & Lyons, 2010b), which is costly
(Leslie & Rosenheck, 2012). is is particularly trouble-
some given that few medications are FDA-approved for
children. State Medicaid programs allow for more oce
visits when there is a severe diagnosis, and Supplemental
Security Income (SSI) eligibility is easier to obtain with a
severe diagnosis, both of which probably contribute to the
increase in severe diagnoses and heavy medications (Lit-
trell & Lyons, 2010b). Recently, push-back on these issues
has occurred. On December 1, 2011, U.S. Senator Tom
Carper held a hearing on the report of the U.S. Govern-
ment Accountability Oce (GAO) investigating medica-
tion of foster children. In several states, doses were found
that exceeded the maximum levels approved by the FDA.
Across states, 0.11–1.33% of children were being treated
concurrently with more than ve medications. Accord-
ing to the GAO panel, “Our experts also said that no evi-
dence supports the use of ve or more psychotropic drugs
in adults or children, and only limited evidence supports
the use of even two drugs concomitantly in children”
(GAO testimony, 2011, p. 14).
Concerns regarding prepsychosis. In addition to con-
cerns about the rise in atypical antipsychotic medication
use for children, Frances (2011a) also expressed concern
about the inclusion of a prepsychosis diagnosis in the im-
pending DSM-5. Frances reported that attempts to iden-
tify those individuals who would later become psychotic
have yielded high levels of false positives (see ompson,
Nelson, & Yung, 2011). Antipsychotics have failed to
prevent the emergence of psychosis in high-risk groups
(Marshall & Rathbone, 2011; although the salubrious
Omega-3 fatty acids have demonstrated ecacy in pre-
venting the emergence of psychosis in those at high risk—
see Amminger et al., 2010). Frances fears a new diagnosis
of prepsychosis could result in many more individuals
being stigmatized and placed on ineective medications
with severe adverse eects. Social worker researchers
should endeavor to identify social factors that prevent the
emergence of psychosis in those who are at risk so that
prevention strategies can be developed.
Limiting diagnoses without drug treatments. Ironi-
cally, the DSM-5 Committee on Autism Spectrum Disor-
ders has suggested more stringent criteria. Dr. Fred Volk-
mar, director of the Child Study Center at the Yale School
of Medicine, forecasted that the new criteria would dis-
qualify many of the individuals who are currently being
treated. Consumer advocates have protested the tighten-
ing of criteria for autism spectrum disorders, fearing the
loss of insurance coverage of nonpharmaceutical treat-
ments (Carey, 2012). Since social workers provide services
to the developmentally disabled, this change could limit
the ability of social workers to serve their clients.
Controversy about the ecacy of antidepressants.
e questionable use of antipsychotics is only one of the
latest controversies in psychiatry. Speaking more broadly,
omas Insel, current director of the National Institute
of Mental Health (NIMH), reected, “e unfortunate
reality is that current medications help too few people get
better and very few people to get well” (2009, p. 704). In
Anatomy of an Epidemic, Whitaker (2010) examined each
category of psychotropic medication in turn. He con-
trasted current outcomes of psychiatric disorders with
outcomes for these same disorders prior to the advent of
drugs. Surprisingly, not only are current outcomes not
any better than those prior to drugs, but for major depres-
sion and for bipolar disorder, current treatment seems to
contribute to chronicity. Whitaker’s book was reviewed
in New York Review of Books in the summer of 2011 by
Marcia Angell, the former editor of e New England
Littrell & Lacasse | Controversies in Psychiatry and DSM-5: The Relevance for Social Work (
Occasional Essay
)
267
Journal of Medicine. Angell pointed out the lack of data
on long-term outcomes with psychiatric medications;
placebo-controlled trials, oen sponsored by industry,
evaluate outcomes aer only 8 weeks. Moreover, there are
no denitive tests for any of the diagnoses in the DSM.
Angell did not disagree with Whitaker’s conclusions (An-
gell, 2011a, 2011b, 2011c).
An exchange between Angell and several psychiatrists
(i.e., Oldham, Friedman, Nierenberg, and Carlat) later
was published in the New York Review of Books (2011c).
In response to Angell in the exchange, Oldham argued
that depression is undertreated and that psychiatry, as a
whole, has never argued that “chemical imbalances are
causes of mental disorders or the symptoms of them”
(Angell, 2011c, p. 82). Friedman and Nierenberg, in re-
sponse to Angell, argued that physicians in other areas
of medicine treat before they understand the conditions
they are treating. Also, in response to Angell, Carlat cited
Turner and Rosenthal’s (2008) defense of antidepressants,
who wrote, “When considering the potential benets of
treatment with antidepressants, be circumspect but not
dismissive” (p. 51).
The Larger Context
e subtext of the current controversies refers to cor-
ruption in the process of the writing of the DSM-5. e
obvious “elephant in the room” behind the rise in psy-
chiatric diagnoses is the unhealthy relationship between
academic psychiatry and the pharmaceutical industry.
U.S. Senator Charles Grassley’s Finance Committee in-
vestigated the degree to which prominent psychiatrists
who set standards for practice are paid by industry, re-
vealing that several had failed to disclose the extent of
their nancial ties to drug companies (Harris & Carey,
2008). Others have decried the inuence of pharmaceu-
tical houses in medicine (Bremner, 2011; Elliot, 2010;
Sinaikin, 2010). is potential for inuence extends to
DSM-5 task force members, many of whom have nan-
cial ties to the pharmaceutical industry (Cosgrove &
Krimsky, 2012).
Angell (2005) has published extensively on the broader
issue of the pharmaceutical industry and purveyors of de-
vices inuencing students in medical school with biased
information. Most of the clinical trials in this country are
funded by industry, and only positive ndings are pub-
lished (Turner, Matthews, Linardatos, Tell, & Rosenthal,
2008). Given the rampant ghostwriting by industry in
medical journals (Lacasse & Leo, 2010), industry-funded
studies are sometimes best regarded primarily as market-
ing eorts rather than truth-seeking endeavors. How is
the reader of journal articles to know when these inu-
ences are or are not present? e ramications of this
commercial inuence on the interrelated practice of di-
agnosis and treatment by social workers are dicult to
quantify, but certainly our profession must wrestle with
these issues.
Action Strategies for Social Work Professionals
So how should social workers respond to these develop-
ments? e APA has not taken a position on the online
petition to the DSM-5 Task Force, although a special
e-mail was sent to members to alert them to an article
by Rebecca Clay in the February 2012 issue of Monitor.
Clay (2012) pointed out that most psychologists use the
World Health Organization’s International Classication
of Diseases rather than the DSM. Indeed, Frances (2011c)
has suggested that mental health professionals can defect
from using the DSM in rendering diagnoses if eorts to-
ward reform are unheeded. e National Association of
Social Workers (NASW) announced the petition on its
website but has not taken an ocial position. Given the
social justice orientation of our profession and our histo-
ry of critical engagement with the issue of diagnosis (e.g.,
Kutchins & Kirk, 1992; Saleebey, 2001), social workers
should read and consider signing the petition. On a macro
level, NASW should consider entering this debate, partic-
ularly regarding the diagnosis of foster children and other
vulnerable populations. Practicing social workers should
familiarize themselves with the many controversies re-
lated to DSM-5 (only a few of which are addressed here),
so that they can apply critical thinking to the question of
diagnoses relevant to their practice context. In particular,
practitioners should consider whether certain diagnostic
labels drive the prescription of psychiatric medications to
their clients, and whether other explanations or labels for
behavior might instead facilitate the use of eective psy-
chosocial interventions for client problems (e.g., should
major depression be diagnosed and antidepressants used
in the wake of a major loss? See Horowitz & Wakeeld,
2007). While DSM clearly serves a valid bureaucratic pur-
pose as a vehicle for reimbursement, these controversies
illustrate the debatable science underlying many of the
DSM categories. Social work researchers should be aware
that NIMH now recognizes the problems with DSM and
that the 21st-century research agenda for studying mental
disorders will change substantially to move beyond such
DSM categories (Insel et al., 2010).
e closely related issue of medication is also important
for social work to address, as social workers are involved
in psychoeducation and related roles (Bentley, Walsh, &
Farmer, 2005). Serving in this role requires considerable
preparation, and social work educators should consider
this reality when developing curricula; course content on
psychiatric drugs should be oered to all clinical students.
In clinical practice, social workers should present full
disclosure regarding any medication discussed. is re-
quires that practicing social workers be familiar with the
ecacy of various medications, including the proportion
of people who respond to drugs as compared to general-
FAMILIES IN SOCIETY | Volume 93, No. 4
268
ized helping or psychotherapy, as well as the probability
of recovering without drugs. To meet our ethical man-
date to our clients, this requires that social workers think
critically about the source of knowledge about psychiatric
drugs and realize the limitations of research produced by
the pharmaceutical industry (Gomory, Wong, Cohen, &
Lacasse, 2011). Social workers should provide informa-
tion about withdrawal phenomena and the short- and
long-term adverse eects of medications. Mental health
practitioners should never instruct a client to stop tak-
ing a medication prescribed by a physician. Social work-
ers can, however, provide documentation of the degree
of ecacy of medications and their adverse eects. en
the client can make an informed decision when talking
with a physician about current medications or have an in-
formed basis for declining a referral for initiating medi-
cations (see Littrell & Ashford, 1995, on legal issues). So-
cial workers should also be familiar with evidence-based
psychosocial alternatives to medication; for instance, use
of behavioral analysis and Vygotsky’s methods (Bodrova
& Leong, 1996) for helping foster children develop self-
control. On a policy level, they should become informed
about the issues regarding medicating foster children and
advocate for stringent guidelines at the state level. Psy-
chrights (http://www.psychrights.org/index.htm) website
describes national protection eorts for children in foster
care and specics in what social workers can do. Finally,
social work researchers should more aggressively probe
the inuence of the pharmaceutical industry on practice
(see Stoesz, 2012) and advocate for more integrity in the
process of conducting studies and disseminating infor-
mation. In an era of evidence-based practice, the verac-
ity and objectivity of peer-reviewed research is a deeply
important issue (Gambrill, 2012).
With regard to further advocacy, the initial phase
is providing documentation of a problem. Hopefully,
this essay will alert the social work community to what
is problematic about the manner in which we currently
conceptualize and respond to human suering. Our hope
is that these issues will be further debated and discussed.
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